Radiographic signs of advanced cerebral venous thrombosis negatively modulate the effectiveness of endovascular treatments.

INTRODUCTION: Endovascular treatment (EVT) is a therapeutic option for cerebral venous thrombosis (CVT); however, its benefit over conservative medical management has not been proven. Whether current patient selection practices are appropriate for EVT is unclear. METHODS: This was a nationwide study of the 2016-2020 National Inpatient Sample database. Adult CVT patients and EVT treatments were identified. Patient demographics, medical comorbidities, CVT risk factors, and CVT manifestations were identified. Presence of radiographic signs of advanced and severe CVT (venous infarction, cerebral edema, and intracranial hemorrhage) were recorded. Primary and secondary outcomes were good discharge outcomes and in-hospital mortality, respectively. RESULTS: 17,130 CVT patients were identified, and 56.7% had good discharge outcomes while 4.6% died during hospitalization. 945 (5.5%) received EVT, and EVT patients were more likely to have cerebral infarction (35.4% vs. 21.8%, p<0.001), edema (35.4% vs. 20.1%, p<0.001), and hemorrhage (37.6% vs. 19.7%, p<0.001). After multivariable adjustments, EVT for patients without infarction, edema, or hemorrhage was moderately associated with higher odds of good outcomes (OR 1.86 [95%CI 0.98 - 3.53], p=0.059) and resulted in zero deaths. However, with increasing burden of radiographic signs of advanced CVT measured by the cumulative presence of infraction, edema, and hemorrhage, EVT was associated with decreasing odds of good outcomes and increasing odds of in-hospital mortality compared to medical management (interaction p=0.046 and 0.029, respectively). CONCLUSIONS: EVT may lead to higher rates of favorable hospitalization outcomes in patients who have not yet developed overt parenchymal manifestations of backpressure changes; presence of infarction, edema, and hemorrhage may diminish the short-term effectiveness of EVT.

First in-human clinical performance of a new non-cavitating handheld lensectomy system in 665 consecutive cataract surgeries.

PURPOSE: To investigate the intraoperative performance and lens fragmentation efficacy of a non-cavitating handheld lensectomy system in mild, moderate, and severe cataract. SETTING: Ambulatory surgical centers. DESIGN: Retrospective consecutive case series. METHODS: 665 consecutive eyes underwent cataract surgery by 12 surgeons using a new handheld non-cavitating lensectomy system for nuclear fragmentations and extraction. Intraoperative measurements included surgical time, miLOOP pretreatment, and irrigation fluid use. RESULTS: Of the 665 eyes, 38 (6%), 468 (70%), 126 (19%), and 33 (5%) were of grade 1, 2, 3, and 4 nuclear densities, respectively, as graded by the surgeon intraoperatively. Successful nuclear fragmentation, lens extraction, and cortical removal were achieved in all eyes. Total nucleus fragmentation and extraction times were 70.1 seconds, 100.3 seconds, 132.6 seconds, and 287.9 seconds for grades 1, 2, 3, and 4, respectively ( P < .001). In addition, irrigation and aspiration cortical removal times were 64.1 seconds, 51.1 seconds, 48.5 seconds, and 59.0 seconds, respectively ( P = .14). There was a low rate of capsular tear (3 cases in 665 surgeries, 0.45%) and no other emergent adverse events. CONCLUSIONS: The miCOR handheld non-cavitating lensectomy system demonstrated nuclear fragmentation and extraction in the absence of intraocular cavitation across all grades of nuclear densities.

Neurological Predictors of Functional Outcome in Cortical Venous Sinus Thrombosis.

Objectives Cerebral venous sinus thrombosis (CVST) has a wide clinical spectrum. Despite favorable prognosis, identifying CVST patients with a possible poor functional outcome can be challenging. This study aims to establish the neurological predictors of outcome in CVST. Materials and Methods We analyzed 70 patients of CVST and categorized them into three groups: Group I with isolated intracranial hypertension; Group II-focal syndrome of neurological deficit; Group III-subacute encephalopathy. Demographic, disease characteristics, and radiological parameters were also analyzed for prediction of hospital course. Functional outcome was assessed by modified Rankin scale (mRS) dichotomized as good (mRS: 0-2) or poor outcome (mRS ≥ 3). Statistical Analysis Univariate and multivariate logistic regression analyses were performed to find out the independent effects of prognostic factors to be used for outcome prediction. Results The mean age was 36.71 ± 14.9 years with 40 (68.8%) males. Most common presenting complaints were headache 35 (50%), hemiparesis 14 (20%), and seizures 12 (17.4%). Group I included 44 (62.9%), group II 17 (24.3%) and group III 12 (12.9%) patients. During hospitalization 28 (40%) patients needed intensive care unit (ICU) care, among them 7 (10%) required ventilation. There were eight times more chances of ICU care (odds ratio [OR]: 7.4; 2.5-24.4) and 23 times more need for ventilation (OR: 23; 2.5-88.9) whenever patients were in group II or III. Good outcome (mRS < 2) was noted in 52 (74.2%) patients. Headache was associated with good functional outcome, whereas hemiparesis with poor outcome. Neurological grouping was the independent predictor of functional outcome; patients with focal neurological deficit (group II) were 20 times more likely to have dependent life at the time of discharge ( p < 0.05) with the mortality rate of 2.9%. Conclusions Neurological grouping is a practical tool for prediction of function outcomes. Early anticipation of prognosis helps in decision-making in the clinical practice.

A technical comparison of thrombectomy vacuum aspiration systems.

INTRODUCTION: Improved functional outcomes after mechanical thrombectomy for emergent large vessel occlusion depend on expedient reperfusion after clinical presentation. Device technology has improved substantially over the years, and several commercial options exist for both large-bore aspiration catheters and suction pump systems. OBJECTIVE: To compare various vacuum pumps and examine the aspiration forces they generate as well as the force of catheter tip detachment from an artificial thrombus. METHODS: Using an artificial thrombus made from polyvinyl alcohol gel, we tested various mechanical characteristics of commercially available suction pumps, including the Penumbra Jet Engine, Penumbra Max, Stryker Medela AXS, Microvention Gomco, and a 60 cc syringe. Both aspiration pressure and tip force generated were analyzed. Subsequently, a cohort of thrombectomy catheters were assessed using the Penumbra Jet Engine to determine tip forces generated on an artificial thrombus. One-way analysis of variance was used to assess statistical significance. RESULTS: The Penumbra Jet Engine system generated both the highest maximum aspiration pressures (28.8 inches Hg) and the highest tip force (23.68 grams force (gf)) on an artificial thrombus, with statistical significance compared with the other pump systems. Using the Jet Engine, the largest-bore catheter was associated with the highest tip force (32.12 gf). The overall correlation coefficient between catheter inner diameter and tip force was 0.98. CONCLUSIONS: The Penumbra Jet Engine pump generates significantly higher vacuum pressures and tip forces than the other commercially available aspiration pump systems. Furthermore, catheters with a larger inner diameter generate higher tip suction forces on aspiration. Whether these mechanical features lead to improved clinical outcomes is yet to be determined.

Investigation of the preliminary mechanism of action for the acute anti-inflammatory activity of the methanol extract of Smilax ornata Lem.

ETHNOPHARMACOLOGICAL RELEVANCE: In folkloric medicine the dried rhizome of the Jamaican sarsaparilla (Smilax ornate Lem.), is given as a decoction to treat chronic rheumatism and rheumatoid arthritis. This particular claim has been scientifically validated; however, the mechanism for its anti-inflammatory activity is still unknown and hence, it forms the reason for this investigation. OBJECTIVE: The objective of this study is to investigate the mechanism of the anti-inflammatory activity of the methanol extract of Smilax ornate Lem. METHOD: The methanol extract was prepared using the soxhlet apparatus. The preliminary mechanism of action was investigated using models of oedema induced by histamine, bradykinin and prostaglandin E2. RESULTS: For the histamine-induced oedema model, the methanol extract (400 mg/kg) reduced the oedema formation, however, it was not significant (P > 0.05). For the bradykinin-induced oedema model, the methanol extract (400 mg/kg) exhibited significant (P < 0.05) anti-inflammatory activity when compared with that of the control (saline) group, with an onset on 60 min and a duration of 2 h. For the prostaglandin-induced oedema model, the methanol extract (400 mg/kg) exhibited significant (P < 0.05) anti-inflammatory activity when compared with that of its control group, with an onset on 120 min and a duration of 1.5 h. CONCLUSION: The methanol extract of Smilax ornata Lem. produced significant anti-inflammatory activity in the bradykinin-induced and prostaglandin-induced oedema models. It is possible that the mechanism by which it acts is by reducing the concentration or blocking the action of these mediators.

The impact of weight loss on cardiac structure and function in obese patients.

BACKGROUND: Obesity frequently results in structural and physiologic changes in the cardiovascular system. Whether weight reduction leads to reversal of these changes is not well-established. This investigation sought to identify the effect of a weight reduction program on right and left ventricular structure and function. METHODS: Sixty-two patients presenting to the eating disorders clinic at a single academic institution for weight loss programs were prospectively enrolled. Baseline and follow-up transthoracic echocardiograms were obtained after at least 10% weight reduction or 6 months after baseline echocardiogram. Complete 2-dimensional echocardiograms were performed with M-mode, flow Doppler, and tissue Doppler evaluation. RESULTS: Patients lost an average of 28.2 +/- 3 kg over a period of 266 +/- 36 days. Left ventricular mass decreased significantly from 255.87 +/- 12 to 228 +/- 11 gm. There were no statistically significant changes in contractility or diastolic indices. The ratios of early-to-late diastolic mitral inflow velocities (E/A) increased from 1.30 +/- 0.05 to 1.32 +/- 0.06. The ratio of early mitral flow to early annular velocity (E/Em) also increased from 5.57 +/- 0.22 cm to 5.82 +/- 0.23 cm. Deceleration time increased from 213.26 +/- 5.3 s to 228.47 +/- 5.7 s. CONCLUSIONS: Weight reduction is associated with decrease in left ventricular diastolic size and left ventricular mass. This weight reduction is not associated with statistically significant improvement in systolic or diastolic function.

Investigation of the anti-inflammatory and the analgesic effects of the extracts from Smilax ornata Lem. (Jamaican sarsaparilla) plant.

ETHNOPHARMACOLOGICAL RELEVANCE: Smilax ornata Lem. is used in folklore medicine to treat rheumatoid arthritis and rheumatic pain. This particular claim has never been scientifically validated before in this plant species and hence, it forms the reason for this investigation. OBJECTIVE: To investigate whether the methanol and ethyl acetate extracts of Smilax ornata Lem. possess anti-inflammatory and analgesic properties in Sprague-Dawley rats. METHODS: The anti-inflammatory and analgesic activities were investigated using carrageenan-induced paw oedema model and the tail-flick model respectively. RESULTS: The methanol extracts (200 and 400 mg/kg) and the ethyl acetate extract (400 mg/kg) exhibited significant (P < 0.05) anti-inflammatory activity when compared with that of their control groups (saline and vegetable oil respectively), with an onset of 150 min and a duration of 2.5 h. The methanol extract (200 mg/kg) exhibited significant (P < 0.05) analgesic activity, with an onset of 60 min and a duration of 2 h. Also, the methanol and the ethyl acetate extracts (400 mg/kg) exhibited significant (P < 0.05) analgesic activity when compared with that of their control groups (saline and vegetable oil respectively), with an onset of 30 min and a duration of 2.5 h. CONCLUSION: The present study provided scientific justification that the extracts of Smilax ornata Lem. possess significant anti-inflammatory and analgesic activities.

Analgesic efficacy of laparoscopic-guided transverse abdominis plane block using liposomal bupivacaine in bariatric surgery.

BACKGROUND: Postoperative pain management is a major contributor to recovery and discharge in bariatric surgery. Local anesthetic agents are of particular interest: they're non-sedating and may reduce postoperative pain and hospital length of stay (LOS). DESIGN: Researchers queried the Bariatric Surgery Service Database for patients undergoing laparoscopic weight loss surgery from January 2012-December 2014. Patients were divided between those who did and did not receive liposomal bupivacaine intra-operatively. Measures included demographics, narcotic use, LOS, antiemetic use, and pain scales. RESULTS: The liposomal group consisted of 233 patients and the PCA group consisted of 243 patients. The liposomal group had significantly less narcotic use than the PCA group in terms of IV morphine equivalents. This did not translate into a reduction in LOS in the liposomal group. CONCLUSIONS: TAP block using liposomal bupivacaine provides effective analgesia comparable to PCA.

Nontraumatic Fat Embolism Found Following Maternal Death after Cesarean Delivery.

Introduction Fat embolism is a rare form of nonthrombotic embolization. Limited literature exists regarding the diagnosis of fat embolism during the perinatal period. We present the first case of maternal death that resulted from nontraumatic fat embolization following Cesarean delivery. Case Description A 29-year-old gravida 1 with a complex medical and surgical history underwent a primary Cesarean delivery at term. On postoperative day 2 the patient was found to be unresponsive. Despite resuscitative efforts, the patient succumbed. Autopsy findings were remarkable for diffuse pulmonary fat emboli. Furthermore, there was no histological evidence of either amniotic fluid embolism or thromboembolism. The primary cause of death was attributed to nontraumatic fat embolization. Discussion Multiple risk factors may have contributed to the development of nontraumatic fat embolization in our patient. Obstetricians should maintain a high level of suspicion for nontraumatic fat embolization in cases of maternal respiratory decompression and sudden maternal mortality.

Yield of CT perfusion for the evaluation of transient ischaemic attack.

BACKGROUND: Magnetic resonance diffusion-weighted imaging and perfusion-weighted imaging are able to identify ischaemic 'footprints' in transient ischaemic attack. Computed tomography perfusion (CTP) may be useful for patient triage and subsequent management. To date, less than 100 cases have been reported, and none have compared computed tomography perfusion to perfusion-weighted imaging (PWI). We sought to define the yield of computed tomography perfusion for the evaluation of transient ischaemic attack. METHODS: Consecutive patients with a discharge diagnosis of possible or definite transient ischaemic event who underwent computed tomography perfusion were included in this study. The presence of an ischaemic lesion was assessed on noncontrast computed tomography, automatically deconvolved CTPTMax (Time till the residue function reaches its maximum), and when available on diffusion-weighted imaging and PWITMax maps. RESULTS: Thirty-four patients were included and 17 underwent magnetic resonance imaging. Median delay between onset and computed tomography perfusion was 4·4 h (Interquartile range [IQR]: 1·9-9·6), and between computed tomography perfusion and magnetic resonance imaging was 11 h (Interquartile range: 3·8-22). Noncontrast computed tomography was negative in all cases, while CTPTMax identified an ischaemic lesion in 12/34 patients (35%). In the subgroup of patients with multimodal magnetic resonance imaging, an ischaemic lesion was found in six (35%) patients using CTPTMax versus nine (53%) on magnetic resonance imaging (five diffusion-weighted imaging, nine perfusion-weighted imaging). The additional yield of CTPTMax over computed tomography angiography was significant in the evaluation of transient ischaemic attack (12 vs. 3, McNemar, P = 0·004). CONCLUSIONS: CTPTMax found an ischaemic lesion in one-third of acute transient ischaemic attack patients. Computed tomography perfusion may be an acceptable substitute when magnetic resonance imaging is unavailable or contraindicated, and has additional yield over computed tomography angiography. Further studies evaluating the outcome of patients with computed tomography perfusion lesions in transient ischaemic attack are justified at this time.

Predictors of Hospital Readmission after Bariatric Surgery.

BACKGROUND: Identification of factors that might predict readmission after bariatric surgery could help surgeons target high-risk patients. The purpose of this study was to identify comorbidities, surgical variables, and postoperative complications associated with readmission. STUDY DESIGN: Patients with bariatric surgery as their primary procedure were identified from the 2012 American College of Surgeons (ACS) NSQIP database. Patient variables, operative times, and major postoperative complications were analyzed for predictors of readmission. The ACS NSQIP estimated probability of morbidity (MORBPROB) was also considered. Chi-square tests and Poisson regression were used for statistical analysis to identify significant predictors. RESULTS: There were 18,186 patients who met inclusion criteria. There were 1,819 who had a laparoscopic gastric band, 9,613 who had laparoscopic Roux-en-Y gastric bypass (RYGB), 6,439 who had gastroplasties (vertical banded gastroplasty and sleeve), and 315 who had open RYGB. Age, sex, BMI, American Society of Anesthesiologists (ASA) class, diabetes, hypertension, steroid use, type of procedure, and operative time all were significantly associated with readmission within 30 days of operation. All major postoperative complications were significant predictors of readmission. Patients expected to be at high risk based on the ACS NSQIP MORBPROB had a significantly higher rate of readmissions. The overall readmission rate for patients undergoing bariatric surgery was 5%. The readmission rate among patients with any major complication was 31%. CONCLUSIONS: Bariatric surgery is a low-risk procedure. Complexity of operation, ASA class, prolonged operative time, and major postoperative complications are important determinants of high risk for readmission. The ACS NSQIP MORBPROB may be a useful tool to identify and target patients at risk for readmission.

Acute and chronic fetal anemia as a result of fetomaternal hemorrhage.

Introduction. Fetomaternal hemorrhage represents a transfer of fetal blood to the maternal circulation. Although many etiologies have been described, most causes of fetomaternal hemorrhage remain unidentified. The differentiation between acute and chronic fetomaternal hemorrhage may be accomplished antenatally and may influence perinatal management. Case. A 36-year-old gravida 6 para 3 presented at 37 and 5/7 completed gestational weeks with ultrasound findings suggestive of chronic fetal anemia such as right ventricular enlargement, diminished cerebral vascular resistance, and elevated middle cerebral artery end-diastolic velocity. On the other hand, signs of acute fetal decompensation such as deterioration of the fetal heart tracing, diminished biophysical score, decreased cord pH, and increased cord base deficit were noted. Following delivery, the neonate's initial hemoglobin was 4.0 g/dL and the maternal KB ratio was 0.015 indicative of a significant fetomaternal hemorrhage. Discussion. One should consider FMH as part of the differential diagnosis for fetal or immediate neonatal anemia. We describe a unique case of FMH that demonstrated both acute and chronic clinical features. It is our hope that this case will assist practitioners in differentiating acute FMH that may require emergent delivery from chronic FMH which may be able to be expectantly managed.

Drug-Induced QT Prolongation as a Result of an Escitalopram Overdose in a Patient with Previously Undiagnosed Congenital Long QT Syndrome.

We present a case of drug-induced QT prolongation caused by an escitalopram overdose in a patient with previously undiagnosed congenital LQTS. A 15-year-old Caucasian female presented following a suicide attempt via an escitalopram overdose. The patient was found to have a prolonged QT interval with episodes of torsades de pointes. The patient was admitted to the telemetry unit and treated. Despite the resolution of the torsades de pointes, she continued to demonstrate a persistently prolonged QT interval. She was seen by the cardiology service and diagnosed with congenital long QT syndrome. This case illustrates the potential for an escitalopram overdose to cause an acute QT prolongation in a patient with congenital LQTS and suggests the importance of a screening electrocardiogram prior to the initiation of SSRIs, especially in patients at high risk for QT prolongation.

Thoracic ganglioneuromas resulting in nonimmune hydrops fetalis.

Introduction Most often, ganglioneuromas affect older pediatric and adult patients. They are typically slow growing tumors that remain clinically silent until they become large enough to cause symptoms by compression of adjacent structures. Case We report a case of a 22-year-old Hispanic gravida 2 para 1 female patient who was found to have massive hydrops fetalis at 20 completed gestational weeks. Fetal echocardiography revealed a narrowed distal ductal arch and proximal descending aorta. Cesarean delivery was undertaken at 29 completed gestational weeks for refractory labor and nonreassuring fetal status. The neonate expired at 47 minutes of life despite aggressive resuscitation. At autopsy, multiple thoracic masses were found adjacent to a compressed proximal descending aorta. Histological and immunohistochemical analysis confirmed the diagnosis of a ganglioneuroma, a rare type of neural crest tumor. Discussion A variety of intrathoracic masses have previously been reported to cause hydrops fetalis including teratomas, fibrosarcomas, and lymphangiomas. To our knowledge, this case is the first description of hydrops fetalis caused by ganglioneuromas. We propose that multiple thoracic ganglioneuromas led to biventricular distal outflow tract obstruction and hydrops fetalis.

Primary congenital lymphedema complicated by hydrops fetalis: a case report and review of the literature.

Introduction. Primary congenital lymphedema is a rare disorder associated with insufficient development of lymphatic vessels. Usually most patients present with lower extremity edema seen sonographically. Rarely primary congenital lymphedema may be associated with severe lymphatic dysfunction resulting in hydrops fetalis. Case. A 27-year-old primigravida with a family history of leg swelling throughout multiple generations was diagnosed early in the third trimester with hydrops fetalis. Delivery was undertaken at 32 weeks for nonreassuring fetal status and the infant expired at approximately 45 minutes of life. Primary congenital lymphedema was confirmed via molecular testing of the vascular endothelial growth factor receptor-3 gene. Discussion. The diagnosis of PCL is suspected prenatally when ultrasound findings coincide with a positive family history of chronic lower limb lymphedema. Isolated PCL is rarely associated with significant complications. Rarely, however, widespread lymphatic dysplasia may occur, possibly resulting in nonimmune hydrops fetalis.

Steroid cell ovarian neoplasm, not otherwise specified: a case report and review of the literature.

Background. Steroid cell ovarian tumors, not otherwise specified, represent a unique cause of female virilization. Most commonly encountered in premenopausal women, these tumors can exist throughout a women's lifetime, from before puberty until after menopause. Case. Steroid cell, not otherwise specified, was diagnosed in a 70-year-old female significant for hirsutism. The patient demonstrated elevated total testosterone levels with normal gonadotropins, DHEA, and DHEA-S levels. CT imaging revealed a right ovarian mass and subsequent laparoscopic right oophorectomy yielded clinical improvement promptly. Conclusion. Virilization in females can occur based on ovarian or adrenal pathology. In terms of ovarian-based female virilization, many tumors exist that may induce women to demonstrate masculine features, such as pure Sertoli, pure Leydig, Sertoli-Leydig combinations, and gynandroblastomas. Each of these tumor types possesses a unique histologic pattern that allows for pathologic identification after removal. A rare source of ovarian-based female virilization is steroid cell neoplasms, not otherwise specified, that do not demonstrate these specific histologic characteristics and thus represent a diagnosis of exclusion after other causes of ovarian-based female virilization have been ruled out.

Vascular causes of radiculopathy: a literature review.

BACKGROUND CONTEXT: Vascular etiologies are a significant source of radiculopathy. The entities that are reviewed here include epidural spinal hematoma, subdural spinal hematoma, spinal arteriovenous malformation, vertebral hemangioma, spinal epidural cavernous hemangioma, vertebral artery anomalies (both tortuosity and dissection), aortic aneurysm, hemorrhagic synovial cysts, ligamentum flavum hematoma, and venous varices. The incidence, pathophysiology, typical clinical presentation, appropriate diagnostic workup, and management are summarized. PURPOSE: To review and summarize various vascular causes of radiculopathy and how it impacts the management of patients with radicular spinal pain. STUDY DESIGN: Literature review. METHODS: An extensive literature review was done on each of the vascular entities and their presentation as radiculopathy. RESULTS: Vascular etiologies of radiculopathy may be underestimated in the literature. Imaging in addition to the history and physical examination is essential to identifying vascular sources of radiculopathy and establishing correct treatment. CONCLUSIONS: In examining patients with radicular pain, extraspinal causes of radiculopathy including vascular entities should be included in the differential. Knowledge of the incidence, pathophysiology, clinical presentation, and management of the possibly underreported various vascular causes of radiculopathy increase the ability of the physician to provide optimal care for the patient. A key aspect to identifying such vascular lesions is appropriate imaging for documenting the source of radiculopathy. Blind injections, done without appropriate imaging for identifying the cause of radiculopathy, and also performed without fluoroscopic guidance, increase not only the risk of misdiagnosis but also the comorbidities associated with spinal injections.