Acute Extra-Arachnoid Subdural Hematomas in Patients 50 Years and Older: When Subdurals Act Like Epidurals.

BACKGROUND: Some patients with subdural hematoma (SDH) with acute extra-arachnoid lesions and without concomitant subarachnoid blood or contusions may present in similarly grave neurological condition compared with the general population of patients with SDH. However, these patients often make an impressive neurological recovery. This study compared neurological outcomes in patients with extra-arachnoid SDH with all other SDH patients. METHODS: We compared a prospective series of extra-arachnoid SDH patients without subarachnoid hemorrhage or other concomitant intracranial injury with a Transforming Research and Clinical Knowledge in TBI control group with SDH only. We performed inverse probability weighting for key characteristics and ordinal regression with and without controlling for midline shift comparing neurological outcomes (Extended Glasgow Outcome Scale score) at 2 weeks. We used the Corticosteroid Randomization After Significant Head Injury prognostic model to predict mortality based on age, Glasgow Coma Scale score, pupil reactivity, and major extracranial injury. RESULTS: Mean midline shift was significantly different between extra-arachnoid SDH and control groups (7.2 mm vs. 2.7 mm, P < 0.001). After weighting for group allocation and controlling for midline shift, extra-arachnoid SDH patients had 5.68 greater odds (P < 0.001) of a better 2-week Extended Glasgow Outcome Scale score than control patients. Mortality in the extra-arachnoid SDH group was less than predicted by the Corticosteroid Randomization After Significant Head Injury prognostic model (10% vs. 21% predicted). CONCLUSIONS: Patients with extra-arachnoid SDH have significantly better 2-week neurological outcomes and lower mortality than predicted by the Corticosteroid Randomization After Significant Head Injury model. Neurosurgeons should consider surgery for this patient subset even in cases of poor neurological examination, older age, and large hematoma with high degree of midline shift.

Analysis of sulfur compounds for crude oil fingerprinting using gas chromatography with sulfur chemiluminescence detector.

Oil spills are a severe problem worldwide due to the resulting damage to marine and coastal ecosystems and to local economies. Identification of the source of spilled oils can be challenging, especially if the oils have undergone severe weathering. Due to their high durability, biomarker compounds (e.g. hopanes, steranes) are widely used for oil fingerprinting. Some sulfur-containing heterocyclic compounds e.g. alkylated dibenzothiophenes are also considered to be highly resistant. In this study, the use of Gas Chromatography with Sulfur Chemiluminescence Detection was investigated as a means of oil fingerprinting using the distribution the sulfur compounds in five different fresh and weathered crude oils. Chemometric analysis was also performed. The results indicate that the sulfur compounds distribution is unique for each crude oil. The distributions of the heavy sulfur compounds (i.e., C2DBTs and C3DBTs) are unchanged after weathering. Therefore, the GC-SCD technique can be considered to support the oil spill identification.

Three-dimensional assessment of vascular cooling effects on hepatic microwave ablation in a standardized ex vivo model.

The aim of this study was a three-dimensional analysis of vascular cooling effects on microwave ablation (MWA) in an ex vivo porcine model. A glass tube, placed in parallel to the microwave antenna at distances of 2.5, 5.0 and 10.0 mm (A-V distance), simulated a natural liver vessel. Seven flow rates (0, 1, 2, 5, 10, 100, 500 ml/min) were evaluated. Ablations were segmented into 2 mm slices for a 3D-reconstruction. A qualitative and quantitative analysis was performed. 126 experiments were carried out. Cooling effects occurred in all test series with flow rates ≥ 2 ml/min in the ablation periphery. These cooling effects had no impact on the total ablation volume (p > 0.05) but led to changes in ablation shape at A-V distances of 5.0 mm and 10.0 mm. Contrary, at a A-V distance of 2.5 mm only flow rates of ≥ 10 ml/min led to relevant cooling effects in the ablation centre. These cooling effects influenced the ablation shape, whereas the total ablation volume was reduced only at a maximal flow rate of 500 ml/min (p = 0.002). Relevant cooling effects exist in MWA. They mainly depend on the distance of the vessel to the ablation centre.

Combination therapy with remdesivir and monoclonal antibodies protects nonhuman primates against advanced Sudan virus disease.

A major challenge in managing acute viral infections is ameliorating disease when treatment is delayed. Previously, we reported the success of a 2-pronged mAb and antiviral remdesivir therapeutic approach to treat advanced illness in rhesus monkeys infected with Marburg virus (MARV). Here, we explored the benefit of a similar combination therapy for Sudan ebolavirus (Sudan virus; SUDV) infection. Importantly, no licensed anti-SUDV therapeutics currently exist, and infection of rhesus macaques with SUDV results in a rapid disease course similar to MARV with a mean time to death of 8.3 days. When initiation of therapy with either remdesivir or a pan-ebolavirus mAb cocktail (MBP431) was delayed until 6 days after inoculation, only 20% of macaques survived. In contrast, when remdesivir and MBP431 treatment were combined beginning 6 days after inoculation, significant protection (80%) was achieved. Our results suggest that combination therapy may be a viable treatment for patients with advanced filovirus disease that warrants further clinical testing in future outbreaks.

Surgical Experience in Prevention of Postoperative CSF Leaks Using Abdominal Fat Grafts in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas.

Objective Cerebrospinal fluid (CSF) leaks are the most common complication during endonasal endoscopic transsphenoidal approach (EETSA) and prevention of postoperative CSF leaks is critical. In this study, we report a single surgeon's experience of sellar floor reconstruction using abdominal fat grafts for prevention of postoperative CSF leaks in EETSA for pituitary adenomas. Study Design This study is presented as case series with retrospective chart review. Setting Present study was conducted at tertiary referral center. Participants A total of 216 patients who underwent surgery via EETSA for pituitary adenomas between 2008 and 2018 at our institution were evaluated. When an intraoperative CSF leak occurred, sellar floor reconstruction was performed using a fat graft harvested from the abdomen via a 2-cm skin incision. Main Outcome Measures Primary outcome and measures of this study was postoperative CSF leaks. Results A total of 53 patients showed intraoperative CSF leaks (24.5%) and 2 patients showed postoperative CSF leaks (0.93%). There were no postoperative CSF leaks in any patients who showed intraoperative CSF leaks and received sellar floor reconstruction using fat grafts. There were also no postoperative CSF leaks in 12 patients who received preventative sellar floor reconstruction using fat grafts due to extensive arachnoid herniation without intraoperative CSF leaks. However, there were two postoperative CSF leaks in patients who did not show intraoperative CSF leaks and did not receive sellar floor reconstruction. Conclusion The effectiveness of sellar floor reconstruction using abdominal fat grafts in patients receiving EETSA for pituitary adenoma was reported. We suggest that identification of intraoperative CSF leaks is important and preventive sellar floor reconstruction without evidence of intraoperative CSF leaks can also be beneficial.

Preoperative ultrasonography and magnetic resonance imaging evaluation of the position of the neurovascular bundle for Dupuytren's disease of the fifth digit.

BACKGROUND: Dupuytren's contracture (DC) is a fibrosing disor-der that produces pathological subcutaneous nodules and cords in the normal fascia. The isolated occurrence of Dupuytren's disease of the fifth digit is uncommon. This study is aimed to describe the imaging features of an isolated digital cord of the small finger and its relationship with the neurovascular bundle. METHODS: A total of 13 hands in 13 patients who were clinically diagnosed with an isolated occurrence of Dupuytren's disease of the small finger were included between October 2008 and October 2013. Two independent radiologists used ultrasound and magnetic reso-nance imaging (MRI) to record size, signal or echogenicity, contrast enhancement or hyperemia, calcification, and anatomical features of the cord and its relationship with the neurovascular bundle. RESULTS: We found that ultrasound and MRI were accurate for the detection of the cords and neurovascular bundles in the small finger. The intermodality agreement between MRI and ultrasound was 100% for the detection of 6 spiraling bundles containing 13 isolated cords (46.2%). Among the subjects examined, 100% of the hands had ab-ductor digiti minimi (ADM) area involvement, and the distal insertion of the cord was on the ulnar side of the base of the middle phalanx. On MRI, all of the cords showed predominantly low signal intensity on both T1- and T2-weighted images. On ultrasound, the ulnar cord showed a hyperechoic or isoechoic appearance in 69.3% of hands and a hypoechoic appearance in 30.7% of hands. CONCLUSIONS: The spiraling of the bundle in the isolated occurrence of Dupuytren's disease at the small finger is a frequent occurrence. MRI and ultrasound are good imaging modalities for the evaluation of the relationship between the neurovascular bundle and the isolated cord.

Combination therapy protects macaques against advanced Marburg virus disease.

Monoclonal antibodies (mAbs) and remdesivir, a small-molecule antiviral, are promising monotherapies for many viruses, including members of the genera Marburgvirus and Ebolavirus (family Filoviridae), and more recently, SARS-CoV-2. One of the major challenges of acute viral infections is the treatment of advanced disease. Thus, extending the window of therapeutic intervention is critical. Here, we explore the benefit of combination therapy with a mAb and remdesivir in a non-human primate model of Marburg virus (MARV) disease. While rhesus monkeys are protected against lethal infection when treatment with either a human mAb (MR186-YTE; 100%), or remdesivir (80%), is initiated 5 days post-inoculation (dpi) with MARV, no animals survive when either treatment is initiated alone beginning 6 dpi. However, by combining MR186-YTE with remdesivir beginning 6 dpi, significant protection (80%) is achieved, thereby extending the therapeutic window. These results suggest value in exploring combination therapy in patients presenting with advanced filovirus disease.

Return to Golf After Shoulder Arthroplasty: A Systematic Review.

BACKGROUND: The number of golfers aged ≥65 years has increased in recent years, and shoulder arthritis is prevalent in this age group. Guidelines for return to golf (RTG) after shoulder arthroplasty have not been fully established. PURPOSE: To review the data available in the current literature on RTG after shoulder arthroplasty. STUDY DESIGN: Systematic review. METHODS: A systematic review based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Two independent reviewers searched PubMed, Embase, and the Cochrane Library using the terms "shoulder,""arthroplasty,""replacement," and "golf." The authors sought to include all studies investigating RTG after total shoulder arthroplasty (TSA), shoulder hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA). Outcomes of interest included indications for shoulder arthroplasty, surgical technique, rehabilitation protocol, amount of time between surgery and resumption of golf activity, and patient-reported outcome measures. RESULTS: A total of 10 studies were included, 2 of which reported on golf performance after shoulder arthroplasty. The other 8 studies described return to sports after shoulder arthroplasty with golf-specific data for our analysis. Three studies that included patients who underwent TSA reported RTG rates ranging from 89% to 100% after mean follow-up periods of 5.1 to 8.4 months. Two studies included patients who underwent TSA and HA and reported RTG rates of 77% and 100% after mean intervals of 5.8 and 4.5 months, respectively. Two studies included patients who underwent RSA, with RTG rates of 50% and 79% after mean postoperative intervals of 5.3 and 6 months, respectively. One study included only patients undergoing HA, with an RTG rate of 54% and a mean RTG time of 6.5 months. Varying surgical procedures and baseline patient characteristics precluded our ability to draw conclusions regarding surgical technique, rehabilitation protocol, or patient-reported outcome measures among studies reporting these data. CONCLUSION: Most patients who undergo a shoulder arthroplasty procedure can expect to resume playing golf approximately 6 months after the index procedure. The rate of return may be lower after RSA and HA as compared with anatomic TSA. The data presented in our review can help physicians counsel patients who wish to continue golf participation after a shoulder arthroplasty procedure.

Incorporation of transradial approach in neuroendovascular procedures: defining benchmarks for rates of complications and conversion to femoral access.

BACKGROUND: The transradial approach (TRA) has gained increasing popularity for neuroendovascular procedures. However, the experience with TRA in neuroangiography is still in early stages in most centers, and the safety and feasibility of this approach have not been well established. The purpose of this study is to report the safety and feasibility of TRA for neuroendovascular procedures. METHODS: We reviewed charts from six institutions in the USA to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedures through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, complications, and whether there was a crossover to transfemoral access. RESULTS: A total of 2203 patients were included in the study (age 56.1±15.2, 60.8% women). Of these, 1697 (77%) patients underwent diagnostic procedures and 506 (23%) underwent interventional procedures. Successfully completed procedures included aneurysm coiling (n=97), flow diversion (n=89), stent-assisted coiling (n=57), balloon-assisted coiling (n=19), and stroke thrombectomy (n=76). Crossover to femoral access was required in 114 (5.2%). There were no major complications related to the radial access site. Minor complications related to access site were seen in 14 (0.6%) patients. CONCLUSION: In this early stage of transforming to the 'radial-first' approach for neuroendovascular procedures, TRA was safe with low complication rates for both diagnostic and interventional procedures. A wide range of procedures were completed successfully using TRA.

Foot-and-Mouth Disease Virus Serotype O/CATHAY Genome Sequences from Five Outbreaks in Vietnam, 2017 to 2019.

We report the genomes of five foot-and-mouth disease viruses (FMDVs) from distinct provinces in Vietnam. All five viruses were grouped within the O/CATHAY topotype. Sequences contain the full polyprotein coding sequence and partial untranslated regions. These genomes provide critical data on the spread and evolution of FMDVs in the region.

Reoxygenation and Repopulation of Tumor Cells after Ablative Hypofractionated Radiotherapy (SBRT and SRS) in Murine Tumors.

In this work, we investigated the change in tumor microenvironment caused by semi-ablative high-dose irradiation and its implication on tumor cell survival, reoxygenation of hypoxic cells and repopulation in FSaII tumors grown subcutaneously in the hind legs of C3H mice. Tumors were exposed to 10-30 Gy of X-ray radiation in a single exposure, and the vascularity and blood perfusion were assessed based on the levels of CD31 expression and Hoechst 33342 perfusion, respectively. The tumor hypoxia was assessed by staining for pimonidazole adduct formation and the expression of hypoxia-inducible factor-1α (HIF-1α) and carbonic anhydrase 9 (CA9). Tumor cell survival was determined using in vivo-in vitro excision assay method. The proportion of hypoxic cells in the tumor was determined from the surviving cell fraction in tumors exposed to a test dose under aerobic and hypoxic conditions. Radiation expsoure markedly reduced the functional vascularity and blood perfusion, and profoundly increased the expression of HIF-1α and CA9 pointing to an increase in tumor hypoxia. The overall clonogenic cell survival progressively decreased during 2-5 days postirradiation, most likely due to the radiation-induced vascular dysfunction. In turn, the proportion of surviving hypoxic cells decreased over several days postirradiation, presumably due to reoxygenation of hypoxic cells. The oxygen supplied through small fractions of blood vessels that survived the high-dose exposure, together with a reduction of oxygen consumption due to massive cell death, appeared to be the cause of the reoxygenation of hypoxic cells. The surviving tumor cells then subsequently repopulated. The findings from this study using a murine tumor model suggest that the efficacy of stereotactic body radiotherapy (SBRT) and stereotactic radiosurgery (SRS) may be significantly improved by allowing an inter-fraction time for reoxygenation while avoiding repopulation.

First Genome Sequence of Foot-and-Mouth Disease Virus Serotype O Sublineage Ind2001e from Southern Vietnam.

We report the polyprotein coding sequence of the newly defined Ind2001e sublineage of foot-and-mouth disease virus (FMDV) serotype O, isolated from a bovine epithelial tissue sample collected in 2017 in Kon Tum Province, Vietnam. This discovery updates FMDV diversity in Vietnam, has implications for FMDV epidemiology, and influences future vaccine selections.

High-grade Features of Papillary Cystadenocarcinoma of the Parotid Gland.

Papillary cystadenocarcinomas (PCAs) are rare low-grade salivary gland tumors first introduced in the World Health Organization classification in 1991. While classically regarded as a low-grade malignancy, PCAs with more clinically and histologically high-grade features have been reported, reflecting the often-underrecognized morphological diversity of this entity. Although no universally advocated grading system exists, high-grade PCAs tend to demonstrate locally aggressive features, cytologic atypia, high mitotic rate, necrosis, and an absence of papillary features. We present a case of a 51-year-old male with slow-onset, progressive right facial fullness over four years. Contrast-enhanced computed tomography of the neck demonstrated a 3.3 cm peripherally enhancing cystic and solid mass in the right superficial lobe of the parotid gland. Following a superficial parotidectomy and a selective right neck dissection, histopathology demonstrated a large cyst with papillary projections lined with cuboidal cells of mild to moderate atypia and surrounding solid tumor nests. The tumor displayed stromal, lymphovascular, and subcutaneous fibroadipose tissue invasion. One of 12 lymph nodes was positive for metastatic carcinoma without extranodal extension. A diagnosis of intermediate-grade PCA was rendered. This case report summarizes the features typical of high-grade PCAs, the few reported cases of intermediate- and high-grade PCAs within the existing literature and provides a brief overview of the radiological and pathological differential diagnosis when considering a parotid gland PCA.

The epididymal amyloid matrix: structure and putative functions.

BACKGROUND: We previously demonstrated the normal mouse epididymal lumen contains a non-pathological amyloid matrix that surrounds spermatozoa and plays important roles in sperm maturation and protection. OBJECTIVE: The objective herein was to present a review of this work, including studies showing the amyloid structures of four members of the CRES (cystatin-related epididymal spermatogenic) subgroup are integral and essential components of the amyloid matrix. METHODS: We used conformation-dependent reagents that recognize the cross-ß-sheet structure characteristic of amyloid, including thioflavin S (ThS), thioflavin T (ThT), anti-amyloid antibodies, and X-ray diffraction, as well as negative-stain transmission electron microscopy (TEM) to visualize amyloid structures in the epididymal lumen. Antibodies that specifically detect each CRES subgroup family member were also used in indirect immunofluorescence analysis. RESULTS AND DISCUSSION: The epididymal lumen contains an amyloid matrix that surrounds maturing spermatozoa and represents a functional amyloid. Alterations in the structure of the amyloid matrix by the loss of the CRES subgroup members or the overexpression of cystatin C result in epididymal pathologies, including infertility. Preliminary data suggest the epididymal amyloid matrix is structurally and functionally similar to bacterial biofilms. CONCLUSION: Together, these results suggest the amyloid matrix serves important roles in epididymal function including sperm maturation and protection.

"We brought our culture here with us": A qualitative study of perceptions of HPV vaccine and vaccine uptake among East African immigrant mothers.

BACKGROUND: HPV vaccine studies in East African communities are few and focus mainly on Somali women and girls. We examined how HPV vaccine perceptions and uptake are shaped among Somali, Ethiopian, and Eritrean mothers. METHODS: We convened three focus groups in Somali, Amharic, and Tigrinya with mothers of 11-17 year old children. The Socio-Context Framework (social, cultural, and religious factors) and Andersen's Behavioral Model (predisposing, enabling, and need for care factors) informed question development. RESULTS: Negative vaccine perceptions, lack of HPV vaccine knowledge, and concerns about side effects emerged as predisposing factors. Having a provider who engages parents on HPV vaccination and takes responsibility for vaccine-related risks emerged as enabling factors. Availability of vaccine information resources (e.g., person-to-person, word of mouth education for parents) were also enabling factors. Need for care factors included having comprehensive vaccine information, strong recommendation from a doctor, and validation from a co-ethnic medical professional. Women exerted strong social influence on vaccine uptake (social), had concerns about pork gelatin in vaccines (religious), and felt discussions about sex with children were culturally unacceptable (cultural). CONCLUSION: Strategies for vaccine uptake among East African immigrants need to address factors that shape HPV vaccine perceptions for adolescents, caregivers, and providers.

We Should Know Ourselves: Burmese and Bhutanese Refugee Women's Perspectives on Cervical Cancer Screening.

Refugee women are at increased risk for cervical cancer and have low rates of cervical cancer screening both in their countries of origin and in the U.S. Using the Behavioral Model for Vulnerable Populations as a conceptual framework, we conducted eight focus groups with Burmese and Bhutanese refugee women to gather information about factors influencing cervical cancer screening (31 Burmese and 27 Bhutanese participants). Less than one-third (28%) reported being screened for cervical cancer before coming to the U.S. and only 45% reported being screened after resettling in the U.S. Participants had limited knowledge about cervical cancer and the need for screening, and faced multiple barriers including competing priorities and cost. However, trusted providers and interpreters were seen as means of facilitating screening. Cervical cancer screening among Bhutanese and Burmese refugee women could be improved with culturally tailored health education and increased access to female providers and trained interpreters.

Diagnostic and treatment preferences for developmental dysplasia of the hip: a survey of EPOS and POSNA members.

PURPOSE: The aim of this study was to elucidate developmental dysplasia of the hip (DDH) diagnosis and treatment preferences among members of the Pediatric Orthopaedic Society of North America (POSNA) and European Paediatric Orthopaedic Society (EPOS). METHODS: A 54-question survey on DDH diagnosis and treatment preferences was distributed to POSNA and EPOS members. Descriptive statistics were performed. RESULTS: A total of 459 responses were analyzed. Ultrasound was the preferred modality for diagnosing DDH in infants less than six months old; few surgeons preferred radiographs. In all, 57% of POSNA members had radiology technicians perform ultrasounds, only 7% of EPOS members did. The percent coverage defining a dislocated hip varied greatly, the most frequent response being < 20% for POSNA and < 40% for EPOS members. Pavlik harnesses were the most popular harness/brace, used by 90% of POSNA and 71% of EPOS members. POSNA members were more likely than EPOS members to use a rigid abduction brace following initial harness/brace failure. For residual acetabular dysplasia, POSNA members were twice as likely as EPOS members to institute hip abduction bracing. Most surgeons would not perform closed reduction at less than three months of age or open reduction at less than six months of age. Most EPOS -members used traction prior to reduction; few POSNA members did. Few POSNA and EPOS members believed that reduction should be delayed until the ossific nucleus was visible. CONCLUSION: There is great variation in the preferred methods for diagnosing and treating DDH. This survey is the largest transcontinental survey to compile diagnostic and treatment preferences for DDH. With wide variations in practice, there is room for quality improvement.

Results From a Pilot Video Intervention to Increase Cervical Cancer Screening in Refugee Women.

Many refugee women emigrate from countries with high cervical cancer incidence rates and have low rates of cervical cancer screening both before and after resettlement. Refugee women face many barriers to cervical cancer screening, including limited knowledge of cervical cancer and screening recommendations and cultural and linguistic barriers to being screened. Our pilot study aimed to develop and evaluate educational videos to promote cervical cancer screening among Karen-Burmese and Nepali-Bhutanese refugees, two of the largest groups of refugees arriving to the United States in recent years. We developed culturally tailored narrative videos for each ethnic group. Karen-Burmese and Nepali-Bhutanese women ( N = 40) were recruited through community health educators to participate in a pre- and posttest study. We assessed changes in cervical cancer knowledge and intentions to be screened, and satisfaction with the videos. We found that women were significantly more likely to report having heard of a test for cervical cancer and indicated significantly greater intentions to be screened after watching the video. Their knowledge about cervical cancer and screening also improved significantly, and they reported high levels of acceptability with the video. Our results suggest that culturally tailored narrative educational videos were acceptable to the target audiences and may be effective in increasing cervical cancer screening among refugee women. Further research should assess how health care and social service providers could implement video-based interventions to encourage women to be screened for cervical cancer during early resettlement.

Therapeutic treatment of Marburg and Ravn virus infection in nonhuman primates with a human monoclonal antibody.

As observed during the 2013-2016 Ebola virus disease epidemic, containment of filovirus outbreaks is challenging and made more difficult by the lack of approved vaccine or therapeutic options. Marburg and Ravn viruses are highly virulent and cause severe and frequently lethal disease in humans. Monoclonal antibodies (mAbs) are a platform technology in wide use for autoimmune and oncology indications. Previously, we described human mAbs that can protect mice from lethal challenge with Marburg virus. We demonstrate that one of these mAbs, MR191-N, can confer a survival benefit of up to 100% to Marburg or Ravn virus-infected rhesus macaques when treatment is initiated up to 5 days post-inoculation. These findings extend the small but growing body of evidence that mAbs can impart therapeutic benefit during advanced stages of disease with highly virulent viruses and could be useful in epidemic settings.