Location pattern of recurrence of fully resected grade 1 meningiomas.

OBJECTIVE: Meningiomas can lead to significant morbidity and mortality and have recurrence potential. While previous studies have focused on calculating recurrence risk, the precise location of the recurrence has not been delineated. This study aimed to investigate the spatial clustering pattern of recurrence relative to the original surgical bed for surgically treated Simpson Grade I-III, WHO Grade 1 meningiomas. METHODS: Patients diagnosed with grade 1 meningiomas and treated with surgical resection with subsequent recurrence were reviewed. Patient demographics, clinical outcomes, and radiographic characteristics were collected. Radiological images were analyzed to determine the location of recurrence relative to the initial tumor. We characterized recurrence as type A (within the surgical bed), type B (outside of the surgical bed, within 1 cm from the site), and type C (distal ≥ 1 cm of the resection site). RESULTS: Forty-two cases met the inclusion criteria. Twelve patients (29%) were male, and 30 (71%) were female. Median age at first treatment was 47 years, with 5.2 ± 3.4 years until recurrence. Recurrence rate was 54.7% at 5 years and 90.4% at 10 years. Twenty-eight patients (66.7%) had a type A recurrence, 11 (26.1%) had a type B recurrence, and 3 (7.1%) had a type C recurrence. CONCLUSIONS: Our series demonstrates that while lesions often recur within the original lesion site, a significant portion recurs beyond the surgical bed. This highlights the substantial possibility of recurrence outside the resection cavity for fully excised benign meningiomas, which may aid in understanding disease progression and in guiding adjuvant therapy.

Patient/public perceptions on engagement with a medical school: What needs to happen to support authentic and sustained participation.

PURPOSE: Patient/public involvement in health professional education is increasing but remains episodic, narrowly focused, reliant on individual enthusiasts, and lacks supportive institutional infrastructure. There is little evidence-informed practical guidance on how to take a more strategic and formal approach. We undertook a qualitative study to learn from patients and the public how medical schools could engage in an authentic and sustainable way. METHODS: In 2022 we conducted eight focus groups with patients and members of community organizations. Participants were asked about experiences and perceptions of what needs to happen to enable and support them to participate in medical education, barriers to authentic engagement, and how they might be overcome. Recordings were transcribed and data coded inductively. A summary report was circulated to participants for validation of findings. RESULTS: The focus groups were attended by 38 participants representing a wide variety of perspectives. Participants provided practical suggestions that we categorized into six major themes: inviting participation; preparing for participation; supporting participation; increasing and supporting diversity; recognizing participation; institutional buy-in and support. CONCLUSIONS: Individual instructors can enhance authentic patient engagement through recruitment, support and recognition practices. Institutional commitment is required to sustain and widen participation through funding, policies and infrastructure.

Therapists' perspectives on using brain-computer interface-triggered functional electrical stimulation therapy for individuals living with upper extremity paralysis: a qualitative case series study.

BACKGROUND: Brain computer interface-triggered functional electrical stimulation therapy (BCI-FEST) has shown promise as a therapy to improve upper extremity function for individuals who have had a stroke or spinal cord injury. The next step is to determine whether BCI-FEST could be used clinically as part of broader therapy practice. To do this, we need to understand therapists' opinions on using the BCI-FEST and what limitations potentially exist. Therefore, we conducted a qualitative exploratory study to understand the perspectives of therapists on their experiences delivering BCI-FEST and the feasibility of large-scale clinical implementation. METHODS: Semi-structured interviews were conducted with physical therapists (PTs) and occupational therapists (OTs) who have delivered BCI-FEST. Interview questions were developed using the COM-B (Capability, Opportunity, Motivation-Behaviour) model of behaviour change. COM-B components were used to inform deductive content analysis while other subthemes were detected using an inductive approach. RESULTS: We interviewed PTs (n = 3) and OTs (n = 3), with 360 combined hours of experience delivering BCI-FEST. Components and subcomponents of the COM-B determined deductively included: (1) Capability (physical, psychological), (2) Opportunity (physical, social), and (3) Motivation (automatic, reflective). Under each deductive subcomponent, one to two inductive subthemes were identified (n = 8). Capability and Motivation were perceived as strengths, and therefore supported therapists' decisions to use BCI-FEST. Under Opportunity, for both subcomponents (physical, social), therapists recognized the need for more support to clinically implement BCI-FEST. CONCLUSIONS: We identified facilitating and limiting factors to BCI-FEST delivery in a clinical setting according to clinicians. These factors implied that education, training, a support network or mentors, and restructuring the physical environment (e.g., scheduling) should be targeted as interventions. The results of this study may help to inform future development of new technologies and interventions.

Cardiac tamponade as an initial presentation for systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease which follows a relapsing and remitting course that can manifest in any organ system. While classic manifestations consist of arthralgia, myalgia, frank arthritis, a malar rash and renal failure to name a few, cardiac tamponade, however, is a far less common and far more dangerous presentation. We highlight the case of a 61year-old male with complaints of acute onset shortness of breath and generalized body aches associated with a fever and chills in the ER. A bedside echocardiogram revealed a significant pericardial effusion concerning for pericardial tamponade. An emergent pericardiocentesis performed drained 800mL of serosanguinous fluid. While denying a history of any rash, photosensitivity, oral ulcers, or seizures, his physical examination did reveal metacarpal phalangeal joint swelling along with noted pulsus paradoxus of 15-200mmHg. Subsequent lab work revealed ANA titer of 1:630 and anti-DS DNA antibody level of 256IU/mL consistent with SLE. This case highlights cardiac tamponade as a rare but life-threatening presentation for SLE and raises the need to keep it in the differential when assessing patients presenting with pertinent exam findings.

Guiding Principles for Patient and Public Engagement in the Educational Missions of Medical Schools.

PURPOSE: The purpose of this research was to cocreate with patients and the public a set of evidence-informed guiding principles for their authentic, responsive, ongoing, and sustainable engagement in the mission, goals, curriculum, and delivery of medical education. METHOD: A set of guiding principles of relevance to medical education was identified from the literature. Eight focus groups with patients and community members representing a wide variety of perspectives were conducted in April and May 2022. Participants reviewed, prioritized, and discussed the principles and described successful engagement, resulting in 8 guiding principles in priority order. A summary report was circulated to participants for feedback. The principles were reviewed and endorsed by senior leaders in the medical school. RESULTS: The 8 focus groups were attended by 38 people (age range, mid-20s to postretirement; 7 male, 27 female, and 4 unknown gender). Accountability (19%), inclusion (18%), reciprocity (17%), and partnership and shared decision-making (14%) were chosen as the most important principles. They want evidence that their contributions are valued and have made a difference. They want the medical school to include and support a diversity of perspectives that reflect the populations being served by the health care system. They want the medical school to invest in building trusting and respectful long-term relationships with patients and the public. CONCLUSIONS: The guiding principles could be used by medical schools as a starting point to build relationships with their local communities to increase the authentic and sustainable engagement of patients and the public in the educational mission of the medical school.

Impact of day of admission on in-hospital outcomes of cardiogenic shock.

BACKGROUND: The management of cardiogenic shock (CS) requires attentiveness to details and in some cases, invasive interventions. In the past, studies have shown relationships between the day of admission and cardiovascular outcomes. We aim to analyze the trends and in-hospital outcomes of patients admitted with CS over the weekends compared to weekdays. METHOD: We identified all patients with CS from the National Inpatient Sample (NIS) database between 2016 and 2020. Using multivariate logistic regression analysis, baseline demographics and in-hospital outcomes were obtained and compared by weekend or weekday admission. RESULTS: Out of 854,684 CS admissions, 199,255 (23.6%) occurred on weekends. Patients admitted over the weekend had worse outcomes, including higher rates of mortality (aOR 1.09 CI 1.05 - 1.11, p<0.001), cardiac arrest (aOR 1.09 CI 1.04 -1.14, p<0.001), and respiratory failure. We also noted higher percutaneous coronary intervention (PCI) rates (aOR 1.2 CI 1.16 - 1.25, p<0.001) but lower rates of pulmonary artery catheterization (PAC) and post-procedure pneumothorax. Weekend admissions had shorter hospital lengths of stay, and they incurred lower charges ($223,222 vs. $247,908). Between 2016 and 2020, we observed a consistent downward trend in the mortality rates of the weekend and weekday CS admissions, with consistently higher weekend than weekday admissions. CONCLUSION: Weekend admissions for CS are associated with worse outcomes, which have persisted for years. This now begs the question of whether physician dissatisfaction, understaffing, or burn-out are responsible for this finding.

Intraoperative and postoperative complications for repeat high-grade glioma resections with concurrent chemotherapy: patient series.

BACKGROUND: High-grade gliomas are aggressive primary brain tumors, the most common of which is glioblastoma multiforme. Despite advances in treatment, the prognosis for these patients remains poor. The most common chemotherapeutic agents used in the treatment of this pathology include temozolomide (TMZ), procarbazine, lomustine, and vincristine. It is unclear whether chemotherapy should be held during resection for high-grade gliomas, because the perioperative risk profile is not clearly defined. OBSERVATIONS: The authors report a case series of 18 surgeries to investigate the effects of concurrent TMZ and lomustine chemotherapy on surgical complications in patients undergoing repeat resection for recurrent high-grade gliomas. The authors found no postoperative infections, self-limiting postoperative complications, or excessive intraoperative blood loss and found one intraoperative complication. LESSONS: There may not be a need to pause TMZ and lomustine chemotherapy during recurrent resections for high-grade gliomas, and continuing these medications throughout the perioperative period may be appropriate. This case series suggests that patients receiving TMZ and lomustine chemotherapy who need a repeat resection for recurrent high-grade gliomas should consider remaining on their chemotherapy regimen because it has been shown in the literature to improve recurrence-free survival time.

Protein-Energy Malnutrition Is Associated with Worse Outcomes in Patients with Atrial Fibrillation: A Nationwide Analysis.

Protein-energy malnutrition (PEM), which leads to a reduced ability of tissues to regenerate and repair themselves, may exacerbate many chronic diseases, including atrial fibrillation (AF), which occurs as a response of the heart to chronic inflammation. However, population-based studies examining the association between PEM and the prevalence and health care burden of AF are lacking. The aim of this retrospective cohort study was to estimate the impact of PEM on the prevalence and clinical outcomes of hospitalization for AF. The National Inpatient Sample (NIS) 2016 and 2017 datasets were searched for data on hospitalized adult patients with AF as a principal diagnosis; we subsequently identified AF patients with and without PEM as a secondary diagnosis using International Classification of Diseases, Tenth Revision (ICD-10), codes. The primary outcome of our study was inpatient mortality, while the secondary outcomes were hospital length of stay (LOS), total hospital cost (THC), cardiogenic shock, pacemaker insertion, successful ablation, and restoration of cardiac rhythm. Propensity score-weighted analysis was used accordingly to adjust for confounders. Out of 821,630 AF hospitalizations, 21,385 (3%) had PEM. Hospitalization for AF with PEM led to a statistically significant increase in mortality (adjusted odds ratio [aOR], 2.30; 95% confidence interval [CI], 1.93-2.75; P < .001) with an adjusted increase in the THC of $15,113 (95% CI, 11,246-18,980; P < .001), a 2-day increase in the LOS (95% CI, 1.92-2.41; P < .001), increased odds of cardiogenic shock (aOR, 1.36; 95% CI, 1.01-1.85; P = .04), and decreased odds of undergoing successful ablation (aOR, .71; 95% CI,.56-.88; P = .002) and achieving the restoration of cardiac rhythm (aOR, 0.56; 95% CI, 0.49-0.0.63; P ≤ .001) compared to those without PEM. These results indicate that PEM is associated with worse in-hospital outcomes in patients with AF. This potential association suggests that nutritional rehabilitation may be essential for improving hospitalization outcomes in AF patients.

"The Spiked Helmet sign": A harbinger of impending barotrauma.

The 'spiked helmet sign' (SHS) is an electrocardiographic finding associated with critical illness and a high risk of death; It is likened to ST-elevation, leading to harmful coronary imaging despite lack of apparent myocardial infarction. We describe the case of SHS secondary to high ventilation pressures in the setting of Acute Respiratory Distress Syndrome (ARDS) in a critically ill patient who subsequently developed barotrauma.

Sex differences in outcomes of transvenous lead extraction: insights from National Readmission Database.

BACKGROUND: With the growing use of implantable cardiac devices, the need for transvenous lead extraction has increased, which translates to increased procedural volumes. Sex differences in lead extraction outcomes are not well studied. OBJECTIVE: The present study aims at evaluating the impact of sex on outcomes of lead extraction. METHODS: We identified 71,754 patients who presented between 2016 and 2019 and underwent transvenous lead extraction. Their clinical data were retrospectively accrued from the National Readmission Database (NRD) using the corresponding diagnosis codes. We compared clinical outcomes between male and female patients. Odds ratios (ORs) for the primary and secondary outcomes were calculated, and multivariable regression analysis was utilized to adjust for confounding variables. RESULTS: Compared to male patients, female patients had higher in-hospital complications including pneumothorax (OR 1.26, 95% CI (1.07-1.4), P < 0.01), hemopericardium (OR 1.39, 95% CI (1.02-1.88), P = 0.036), injury to superior vena cava and innominate vein requiring repair (OR 1.88, 95% CI (1.14-3.1), P = 0.014; OR 3.4, 95% CI (1.8-6.5), P < 0.01), need for blood transfusion (OR 1.28, 95% CI (1.18-1.38), P < 0.01), and pericardiocentesis (OR 1.6, 95% CI (1.3-2), P < 0.01). Thirty-day readmission was also significantly higher in female patients (OR 1.09, 95% CI (1.02-1.17), P < 0.01). There was no significant difference regarding in-hospital mortality (OR 0.99, 95% CI (0.87-1.14), P = 0.95). CONCLUSION: In female patients, lead extraction is associated with worse clinical outcomes and higher 30-day readmission rate.

New Dual Endothelin Receptor Antagonist Aprocitentan in Hypertension: A Systematic Review and Meta-Analysis.

Hypertension is one of the most common disorders encountered, yet pharmacotherapy for resistant hypertension has limited effective options. Aprocitentan is postulated to be a novel antihypertensive. The main goal was to determine the effect of aprocitentan on blood pressure among patients with hypertension. A thorough search of 5 electronic databases, including PubMed Central, PubMed, EMBASE, Springer, and Google Scholar, was carried out. The study included eight articles. With doses exceeding 25 mg, plasma ET-1(endothelin-1) concentrations, which show ETB (Endothelin receptor type B) receptor antagonism, significantly rose. Aprocitentan significantly reduced systolic and diastolic blood pressure with both doses of 10mg and 25mg in patients with hypertension. Further research is warranted to evaluate the efficacy, safety, and long-term outcomes of aprocitentan and its synergistic effect with other antihypertensives.

Meta-Analysis on Invasive Versus Conservative Strategy in Patients Older Than Seventy Years With Non-ST Elevation Myocardial Infarction.

Management of non-ST elevation myocardial infarction (NSTEMI) has evolved over the years, but most published data are from younger patients. Data on the NSTEMI management in older patients remain limited. We performed a meta-analysis of randomized controlled trials to evaluate the long-term outcomes of invasive versus conservative strategies in older patients (>70 years old) with NSTEMI. Of 1,550 reports searched, 4 randomized controlled trials (1,126 patients) were included in the analysis, with a median follow-up of 1.25 years (range: 1 to 2.5 years). The median age of included patients was 83.6 (interquartile range: 2.8 years). The invasive strategy was associated with significantly lower risk of major adverse cardiac and cerebrovascular event (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40 to 0.91, I2 = 54%; 3 trials] and unplanned revascularization (OR 0.31, 95% CI 0.15 to 0.64, I2 = 1.7%; 3 trials] than was the conservative strategy. There was no difference in all-cause mortality (OR 0.88, 95% CI 0.65 to 1.18, I2 = 0%; 4 trials], myocardial infarction (OR 0.70, 95% CI 0.42 to 1.19, I2 = 54.7%; 4 trials], or bleeding (OR 0.87, 95% CI 0.39 to 1.93, I2 = 0%; 3 trials] between the strategies. In conclusion, the use of initial invasive strategy in older patients presenting with NSTEMI was associated with a significantly lower risk of major adverse cardiac and cerebrovascular event and unplanned revascularization than that of the initial conservative strategy without increased bleeding.

Assessment of childhood obesity in secondary care: OSCA consensus statement.

This expert opinion provides detailed guidance on assessing obesity in secondary paediatric practice. This guidance builds on existing recommendations from National Institute of Health and Clinical Excellence in the UK, and is evidence based where possible. Guidance is provided on which obese children and young people are appropriate to be seen in secondary care and relevant history and investigations, and guidance on when further investigation of causes and obesity-related comorbidity is appropriate.

Apical Hypertrophic Cardiomyopathy Prompting Aneurysm, Thrombus, and Cardiac Arrest in a 56-Year-Old Female.

Hypertrophic cardiomyopathy (HCM) is the most prevalent genetic cardiac disease while apical hypertrophic cardiomyopathy (apHCM) is a rare subset of HCM. The significance of this case report is to present apHCM, its chronological course, and its association with left ventricular aneurysm, thrombosis, and cardiac arrest. We present the case of a 56-year-old female with a past medical history of apHCM who was admitted for substernal chest pain, developed a ventricular storm (VT), and subsequently suffered cardiac arrest; resuscitation of spontaneous circulation (ROSC) was eventually achieved after 10 minutes. It was initially thought that her arrhythmia and hemodynamic decompensation were purely secondary to cocaine use at a party six hours prior to her presentation. During hospitalization, cardiac magnetic resonance imaging demonstrated a severe apHCM apical aneurysm, thrombosis, and a re-entrant circuit as a likely cause of this patient's decompensation and eventual cardiac arrest. After several days of hemodynamic stability and decreased dependence on intravenous antiarrhythmic medication infusions, she was extubated and transitioned to oral amiodarone and beta-blocker therapy with the implantation of a cardioverter-defibrillator (ICD). In this case, we analyze the continuum of apHCM, a rare subset of HCM once thought to be benign but with the emergence of complications, including aneurysm, thrombus formation, resistant ventricular tachycardia, and cardiac arrest. Recognition and management of apHCM with medical and/or surgical intervention are therefore critical to prevent the aforementioned sequela.

Differences According to Sex in Short-term Clinical Outcomes After Supraventricular Tachycardia Catheter Ablation: Insights from the Nationwide Readmission Database.

Catheter ablation is indicated for the management of supraventricular tachycardias (SVTs). We investigated the effect of sex on short-term outcomes after catheter ablation for SVTs other than atrial fibrillation (AF). Using the Healthcare Cost and Utilization Project Nationwide Readmission Database for the years 2016-2018, SVT patients who underwent catheter ablation were identified using the appropriate International Classification of Diseases, 10th Revision, codes. The primary outcome was 30-day readmissions. Secondary outcomes included 30-day readmissions for SVT, postprocedural bleeding, acute myocardial infarction, transient ischemic attack, stroke, hemopericardium, cardiac tamponade, length of stay (LOS) in the hospital, and total hospital charges (in USD). Female sex was not associated with an increased risk of the primary outcome (P = .168) but was associated with a significantly decreased risk of postprocedural revascularization (P = .001), LOS (P = .003), and total hospital charges (P = .002). There were no significant differences in other secondary outcomes. Among patients admitted for catheter ablation for SVTs (other than AF), female sex was associated with decreased LOS and total hospital charges, which may be attributed to increased comorbidity rates in men and gender-based biases.

Impact of Chronic Obstructive Pulmonary Disease on Atrial Fibrillation Ablation Outcomes According to the National Readmission Database.

Chronic obstructive pulmonary disease (COPD) is a risk factor for the development of atrial fibrillation (AF). There is a paucity of contemporary data studying the association between COPD and outcomes of AF ablation. The objective of this study was to investigate the impact of COPD on AF ablation outcomes using a large nationwide database. This study was a retrospective analysis of the National Readmission Database for the years 2016-2018 and included patients admitted with a diagnosis of AF who underwent catheter ablation. Admissions were stratified according to COPD diagnosis using International Classification of Diseases, 10th Revision, Clinical Modification codes. Multivariate, linear, Cox, and logistic regressions were performed to study the impact of COPD on AF ablation. A total of 18,224 admissions (mean age, 68 years; standard deviation, 10 years) were included, of whom 3,494 (19%) had a diagnosis of COPD. The COPD group was older (72 ± 8 vs. 67 ± 11 years, P < .001) and more likely to have congestive heart failure (73% vs. 44%, P < .001) and renal failure (31% vs. 17%, P < .001). COPD was associated with an increased risk of readmission (adjusted hazard ratio [aHR], 1.40; 95% confidence interval [CI], 1.26-1.56; P < .001) and all-cause in-hospital mortality (adjusted odds ratio, 2.83; 95% CI, 1.74-4.60; P < .001). However, COPD was not associated with an increased risk of readmission due to recurrent AF (aHR, 0.97; 95% CI, 0.75-1.27; P = .844) or the need for re-ablation (aHR, 0.85; 95% CI, 0.44-1.65; P = .639), respectively. In conclusion, COPD was not associated with an increased risk of recurrent AF after ablation despite higher periprocedural risks. The present study contributes to a better understanding of this high-risk subgroup of patients undergoing AF ablation.

Anterior-Posterior versus anterior-lateral electrodes position for electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials.

Background: The optimal electrodes position for elective direct current (DC) cardioversion of patients with atrial fibrillation (AF) remains uncertain. Methods: An electronic search of MEDLINE, EMBASE and COCHRANE databases was performed through March 2022 for randomized trials that examined the outcomes of anterior-posterior (AP) versus anterior-lateral (AL) electrodes position during cardioversion of (AF). The main outcome was the success rate of cardioversion. Data were pooled using random effects model. Results: The final analysis included 10 RCTs with a total of 1677 patients. There was no difference in the rate of successful cardioversion between the AP versus AL groups (86.6 vs 87.9 %; RR 1.00; 95 % Confidence Interval (CI) 0.95 to 1.06). Subgroup analysis by the shock waveform showed no significant interaction between monophasic and biphasic waveforms (Pintercation = 0.23). meta-regression analyses showed no effect modification of primary outcome according to body mass index (p = 0.15), left atrial diameter (p = 0.64), valvular heart disease (p = 0.34), lone AF (p = 0.58), or the duration of AF (p = 0.70). There was no significant difference between the AP and AL electrode position groups in successful cardioversion at low energy (RR 0.94; 95 % CI 0.74 to 1.19), the number of the delivered shocks (standardized mean difference [SMD] -0.03; 95 % CI -0.32 to 0.26) or the mean energy of the delivered shocks (SMD -0.11 and 95 % CI -0.30 to 0.07). There was lower transthoracic impedance with AP versus AL electrode position (SMD -0.28; 95 %CI -0.47 to -0.10). Conclusion: Meta-analysis of randomized data showed no difference between AP and AL electrode positions in the success rate of DC cardioversion of AF. Either AP or AL electrode positions should be acceptable approaches for elective DC cardioversion of patients with AF.

Metalinguistic filters within the bilingual language faculty: a study of young English-Chinese bilinguals.

This study reports two metalinguistic parameters that constitute the schematic control of lateral inhibitory links between translation equivalents within the bilingual lexico-semantic system of Green's (Bilingualism: Language and Cognition 1:67-81, 1998a, Bilingualism: Language and Cognition 1:100-104, 1998b, The bilingualism reader, Routledge, London, 2007) inhibitory control (IC) model. Building on Green's postulation that the bilingual lexico-semantic system is controlled by a hierarchy of schemas under a supervisory attentional system, the bilingual unconsciously filters activated lemmas during fluent spontaneous codeswitching, such that lemmas that are semantico-syntactically versatile or morphosyntactically transparent are likely to reach a threshold of activation first while other lemmas are inhibited. To investigate the issue, we collected code-paired naturalistic and elicited data with a focus on code-switched determiner phrases from 140 Mandarin-English simultaneous bilinguals who were post-secondary students in Singapore. We found that the semantico-syntactic and morpho-syntactic dissimilarities between Mandarin and English activated both filters. As most Mandarin determiners are economical vis-à-vis their English counterparts, their lemmas were selected frequently while English lemmas were largely inhibited. It was also found that our participants preferred English nouns in filling the lexical category for their interpretable feature of number, a feature that is normally absent in Mandarin nouns.

Ordered silicon vacancies in the framework structure of the zeolite catalyst SSZ-74.

Physico-chemical characterization of the high-silica zeolite catalyst SSZ-74 (ref. 1) suggested that it, like the related materials TNU-9 (ref. 2) and IM-5 (ref. 3), has a multidimensional 10-ring channel system. Such pore systems are ideal for many petrochemical applications, and indeed SSZ-74 has been shown to be a good catalyst for a wide variety of reactions. The elucidation of its framework structure, however, proved to be difficult. Comparable problems were encountered with TNU-9 and IM-5, which were synthesized with related structure-directing agents. Their framework structures, which are the two most complex ones known, both have 24 Si atoms in the asymmetric unit, and were finally solved by combining high-resolution powder diffraction data with information derived from high-resolution electron microscopy images. Therefore, a similar approach, using the powder charge-flipping algorithm to combine the two types of data and molecular modelling to help to locate the structure-directing agent, was applied to SSZ-74. This procedure eventually revealed a most unusual 23-Si-atom framework structure (|(C(16)H(34)N(2))(4)&Si(92)(4)O(184)(OH)(8)]) with ordered Si vacancies.