Conservative versus Invasive Strategy in Elderly Patients with Non-ST-Elevation Myocardial Infarction: Insights from the International POPular Age Registry.

This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.

An International Retrospective Observational Study of Liver Functional Deterioration after Repeat Liver Resection for Patients with Hepatocellular Carcinoma.

Whether albumin and bilirubin levels, platelet counts, ALBI, and ALPlat scores could be useful for the assessment of permanent liver functional deterioration after repeat liver resection was examined, and the deterioration after laparoscopic procedure was evaluated. For 657 patients with liver resection of segment or less in whom results of plasma albumin and bilirubin levels and platelet counts before and 3 months after surgery could be retrieved, liver functional indicators were compared before and after surgery. There were 268 patients who underwent open repeat after previous open liver resection, and 224 patients who underwent laparoscopic repeat after laparoscopic liver resection. The background factors, liver functional indicators before and after surgery and their changes were compared between both groups. Plasma levels of albumin (p = 0.006) and total bilirubin (p = 0.01) were decreased, and ALBI score (p = 0.001) indicated worse liver function after surgery. Laparoscopic group had poorer preoperative performance status and liver function. Changes of liver functional values before and after surgery and overall survivals were similar between laparoscopic and open groups. Plasma levels of albumin and bilirubin and ALBI score could be the indicators for permanent liver functional deterioration after liver resection. Laparoscopic group with poorer conditions showed the similar deterioration of liver function and overall survivals to open group.

Multicenter Propensity Score-Based Study of Laparoscopic Repeat Liver Resection for Hepatocellular Carcinoma: A Subgroup Analysis of Cases with Tumors Far from Major Vessels.

Less morbidity is considered among the advantages of laparoscopic liver resection (LLR) for HCC patients. However, our previous international, multi-institutional, propensity score-based study of emerging laparoscopic repeat liver resection (LRLR) failed to prove this advantage. We hypothesize that these results may be since the study included complex LRLR cases performed during the procedure's developing stage. To examine it, subgroup analysis based on propensity score were performed, defining the proximity of the tumors to major vessels as the indicator of complex cases. Among 1582 LRLR cases from 42 international high-volume liver surgery centers, 620 cases without the proximity to major vessels (more than 1 cm far from both first-second branches of Glissonian pedicles and major hepatic veins) were selected for this subgroup analysis. A propensity score matching (PSM) analysis was performed based on their patient characteristics, preoperative liver function, tumor characteristics and surgical procedures. One hundred and fifteen of each patient groups of LRLR and open repeat liver resection (ORLR) were earned, and the outcomes were compared. Backgrounds were well-balanced between LRLR and ORLR groups after matching. With comparable operation time and long-term outcome, less blood loss (283.3±823.0 vs. 603.5±664.9 mL, p = 0.001) and less morbidity (8.7 vs. 18.3 %, p = 0.034) were shown in LRLR group than ORLR. Even in its worldwide developing stage, LRLR for HCC patients could be beneficial in blood loss and morbidity for the patients with less complexity in surgery.

Challenges during anaesthetic management of a 38-year-old deaf and mute patient under general anaesthesia.

Congenitally deaf and mute adult patients have speech and language disabilities. Establishing meaningful communication with these patients is a challenge in acute hospital-care settings, particularly when anaesthetic care is to be provided. Several methods can be adopted to facilitate interaction, such as sensitisation of health-care providers and training them in ways to communicate effectively. A thorough preoperative assessment and customised perioperative management satisfying the patients needs will ensure a successful outcome. Implementing pain protocols and using tools such as Visual Analog Scale (VAS) will mitigate stress and surgical related complications.

Thermal stress inside a disabled submarine.

BACKGROUND: Submarine operations require strict adherence to standard operating and safety procedures and errors in judgement or accidents could lead to catastrophe and impair the submarine's ability to surface. In case of disablement of a submarine (DISSUB), the crew would have to survive inside the submarine for a variable period awaiting rescue. Microclimate and habitability of the submarine would have to be maintained and crew would have to consume emergency rations and water. METHODS: In order to validate these procedures, a simulation was carried out in which 80 crew members were closed up inside a submarine in harbour for 24 h simulating a DISSUB situation without power and ventilation. RESULTS: Average temperature of the submarine compartments rose from 29.33 °C at the beginning of the simulation to 33.5 °C at the end of 24 h. Relative humidity increased from 79% to 87.67%. Crew members consumed an average to 973 kcal worth of rations during the 24 h of the exercise with 500 ml water. CONCLUSION: Submarine crew could survive successfully inside a disabled submarine awaiting rescue if thermal stress could be addressed. In the present simulation, the crew suffered from effects of thermal stress. Thermal stress would not only affect damage control capabilities, but could also lead the crew into earlier escape. Greater research and further studies are required to mitigate thermal stress and its effects in order to prolong survival.

The Organisms and Factors Affecting Outcomes of External Ventricular Drainage Catheter-Related Ventriculitis: A Penang Experience.

INTRODUCTION: Ventriculostomy-related infection (VRI) from external ventricular drain (EVD) insertion is a common complication and carries a high mortality rate. Choice of empiric antibiotics depends on the institutions common causative organisms and their susceptibility. We determined risk factors for mortality in patients with VRI, the common organisms causing VRI, and the rate of EVD-related VRI at our institution. METHODS: Medical records and operative data of patients with cerebrospinal fluid positive cultures with an EVD inserted from 2012 to 2015 were traced. Forty-five patients with EVD-related VRI were included in the study. RESULTS: The overall rate of VRI was 6.3%, and the overall mortality rate due to VRI was 48.9%. Acinetobacter baumannii was the most common organism causing VRI (14 patients, 29.2%) with a mortality rate of 64.3%. Only 14.3% of A. baumannii are sensitive to meropenem and imipenem. We found that patients that had a decompressive craniectomy (DC) had a lower mortality rate (P = 0.042) and patients with a longer duration of the EVD being in place before the diagnosis of VRI had poor outcome (P = 0.040). Multivariate logistic regression was performed and we found that the use of steroid (P = 0.014), Pseudomonas aeruginosa infection (P = 0.010), multiple organism infection (P = 0.017), lower Glasgow Coma Scale (P = 0.043), and a longer duration the EVD was in place before the diagnosis of VRI (P = 0.008) were related with higher mortality. CONCLUSION: VRI mortality rate is high with an alarming resistance pattern seen in Acinetobacter VRI. EVDs should be removed as soon as feasible, and DC may be offered to patients with severe ventriculitis or meningitis.

Fatal Intracranial Hemorrhage in a Patient with Severe Dengue Fever.

Dengue fever has been a major cause of morbidity and mortality in subtropical and tropical countries. We report a rare case of severe dengue with spontaneous intracranial hemorrhage. A search of literature through PubMed revealed that the largest series analyzed so far only included five cases. A 47-year-old man presented with 7 days history of fever, headache, myalgia, and vomiting with hematemesis. On the day of presentation, he had reduced consciousness and an episode of generalized tonic-clonic seizure. His Glasgow Coma Scale was E1V1M3 with anisocoria. Postresuscitation computed tomography of the brain revealed a right subdural and left thalamic hemorrhage. His blood investigations revealed thrombocytopenia, dengue virus type 1 nonstructural protein antigen test was positive, dengue IgM negative, and dengue IgG positive. A right decompressive craniectomy was done. Unfortunately, the patient died soon after. Spontaneous intracranial hemorrhage in patients with dengue fever is an uncommon entity but usually carry a grave prognosis. To date, there has been no clear management guideline for such cases, as both operative and nonoperative approaches have their own inherent risks.

Giant cell tumor of temporomandibular joint masquerading as temporomandibular joint pain dysfunction syndrome: a rare case report.

Giant cell tumor (GCT) of the craniofacial bones has been reported but they are not common. This tumor occurs more often in women than in men and predominantly affects patients around the third to fifth decade of life. GCTs are generally benign but can be locally aggressive as well. We report a case of GCT involving the temporomandibular joint (TMJ), which was initially thought to be temporomandibular disorder (TMD). A 22-year-old female presented with swelling and pain over the right temporal region for 18 months associated with jaw locking and clicking sounds. On examination, her jaw deviated to the right during opening and there was a 2×2 cm swelling over the right temporal region. Despite routine treatment for TMD, the swelling increased in size. Computed tomography and magnetic resonance imaging of the brain and TMJ revealed an erosive tumor of the temporal bone involving the TMJ which was displacing the temporal lobe. Surgical excision was done and the tumor removed completely. Histopathological examination was consistent with a GCT. No clinical or radiological recurrence was detected 10 months post-surgery.

Occupational health concerns: An analysis of physical activity of submariners.

BACKGROUND: Submarine crew have low physical activity by virtue of their professional requirements. Lack of space and inadequacy of regeneration capabilities render physical activity almost impossible during deployments. However, sufficient data for physical activity levels and trends are required to measure the magnitude of inactivity. METHODS: Data was collected from 362 personnel belonging to six submarines and one submarine base using Global Physical Activity Questionnaire. Four study groups were defined: Base, Refit, Operational/Harbour and Operational/Sea. RESULTS: Overall, 30.11% of the crew had insufficient physical activity (4.04% in Base, 5.75% in Refit, 15% in Ops/Harbour and 91.67% in Ops/Sea groups). Of the total physical activity, 48.7% was contributed by activity at work, 18.71% by travel related activity and 32.62% by recreational physical activity. Base group recorded the highest recreational activity of 1468.28 Minutes-per-Week. Recreational activity contributed 43.22% to total physical activity for this group. Mean total physical activity was highest for ≥45 years and lowest for ≤24 years. ≥45 years old also recorded the highest recreational activity. CONCLUSION: The greatest cause for concern comes from the crew in operational submarines and the younger crew. Physical activity profile of the crew when at sea cannot be changed and greater research is required to assess the long-term health effects of physical inactivity in this group. However, what can be modified are the work schedules for refit submarines and operational submarines when in harbour. Targeted interventions and strategies are required to establish sustainable behaviour patterns with regards to physical activity in these groups.

Deadly intracranial bleed in patients with dengue fever: A series of nine patients and review of literature.

INTRODUCTION: Dengue fever is a global pandemic threat with increasing incidence. To date, there are no cures and the effectiveness of dengue vaccines is still uncertain. World Heath Organization introduced expanded dengue syndrome to include unusual presentations of dengue fever including severe neurologic complications. One of the deadly complications is intracranial hemorrhage (ICH). METHODOLOGY: We collected data of patients with ICH diagnosed via a plain computed tomography of the brain (CT brain) with thrombocytopenia and positive Dengue virus type 1 nonstructural protein (NS1) antigen test or positive dengue serology IgM from January 2014 till June 2015 at our center. Nine patients were included and all 20 other remaining patients reported in literature so far are discussed. DISCUSSION: We found that all patients in our center requiring neurosurgical intervention died. Another interesting observation is that detection of Dengue IgG usually meant more severe ICH and poorer outcomes. From our series, platelet levels did not seem to influence the outcome. CONCLUSION: We recommend that for early detection of ICH, Dengue IgG should be routinely screened and a high index of suspicion be maintained. Future research should be focused on determining predictors of ICH in patients with dengue fever so that preventive steps can be taken as mortality is high and no treatment seems beneficial at the moment once severe ICH occurs.

New Oligocene primate from Saudi Arabia and the divergence of apes and Old World monkeys.

It is widely understood that Hominoidea (apes and humans) and Cercopithecoidea (Old World monkeys) have a common ancestry as Catarrhini deeply rooted in Afro-Arabia. The oldest stem Catarrhini in the fossil record are Propliopithecoidea, known from the late Eocene to early Oligocene epochs (roughly 35-30 Myr ago) of Egypt, Oman and possibly Angola. Genome-based estimates for divergence of hominoids and cercopithecoids range into the early Oligocene; however, the mid-to-late Oligocene interval from 30 to 23 Myr ago has yielded little fossil evidence documenting the morphology of the last common ancestor of hominoids and cercopithecoids, the timing of their divergence, or the relationship of early stem and crown catarrhines. Here we describe the partial cranium of a new medium-sized (about 15-20 kg) fossil catarrhine, Saadanius hijazensis, dated to 29-28 Myr ago. Comparative anatomy and cladistic analysis shows that Saadanius is an advanced stem catarrhine close to the base of the hominoid-cercopithecoid clade. Saadanius is important for assessing competing hypotheses about the ancestral morphotype for crown catarrhines, early catarrhine phylogeny and the age of hominoid-cercopithecoid divergence. Saadanius has a tubular ectotympanic but lacks synapomorphies of either group of crown Catarrhini, and we infer that the hominoid-cercopithecoid split happened later, between 29-28 and 24 Myr ago.

Circulating endothelial progenitor cells and age-related white matter changes.

BACKGROUND AND PURPOSE: The objective was to evaluate the relationship between circulating endothelial progenitor cells (EPC) and age-related white matter changes (ARWMC). Endothelial dysfunction plays a role in the development of ARWMC. EPC incorporate into sites endothelial damage and are thought to be involved in the repair of vascular risk factor induced endothelial injury. ARWMC can be evaluated using CT or MRI. METHODS: In 172 individuals, circulating EPC were defined by the surface markers CD31 and von Willebrand factor. ARWMC were rated on CT scan using the ARWMC scale and divided into 3 groups based on ARWMC scale score (ARWMC score 0 [none], score 1-10 [mild-to-moderate], score >10 [severe]). Severity of ARWMC was correlated with levels of EPC and vascular risk factors. RESULTS: On univariate analysis, EPC were found to be significantly lower in patients with severe ARWMC (P=0.01). ARWMC were also associated with hypertension (P<0.001), age (P<0.001), creatinine clearance (P=0.031), C-reactive protein (P<0.001), and use of angiotensin-converting enzyme or angiotensin receptor blocker (P=0.004). Multiple logistic regression analysis identified EPC level, age, hypertension, and hypertriglyceridemia as significant independent predictors of severe ARWMC. CONCLUSIONS: Levels of circulating EPC were significantly lower in patients with severe ARWMC. Other variables significantly associated with severe ARWMC were age, hypertension, and hypertriglyceridemia. Further study is required to delineate the pathophysiological relationship between EPC, vascular risk factors, and ARWMC.

Endothelial progenitor cells during cerebrovascular disease.

BACKGROUND AND PURPOSE: Endothelial progenitor cells (EPCs) are associated with endothelial repair after ischemia in cardiac or peripheral circulation. There are no reports of EPCs with cerebrovascular disease. We present our experience with EPCs in patients with cerebrovascular disease. SUMMARY OF REPORT: EPC counts differed significantly (P<0.001) between stroke patients (acute stroke: median 4.75 and range 0 to 33; stable stroke: median 7.25 and range 0 to 43) and control subjects (median 15.5 and range 4.3 to 50), independent of age. The level of EPCs was significantly correlated with the Framingham coronary risk score (FCRS) (rho=-0.349; P=0.002). CONCLUSIONS: Similar to cardiac experience, the low EPC levels may play a role in the pathophysiology of cerebrovascular disease.

Agreement between patient and proxy assessments of health-related quality of life after stroke using the EQ-5D and Health Utilities Index.

BACKGROUND AND PURPOSE: Proxy informants can provide information on patients who are limited in ability to self-assess health-related quality of life (HRQL) after stroke. One alternative is to exclude assessments of such patients and attenuate generalizability. The purpose of this study was to examine patient-proxy agreement on the domains and summary scores of the EQ-5D and Health Utilities Index Mark 3 (HUI3) after stroke. METHODS: An observational longitudinal cohort of 124 patients hospitalized after ischemic stroke and their family caregivers completed the HRQL measures at baseline and were followed up for 6 months. Patient and proxy agreement was assessed by use of weighted kappa or the intraclass correlation coefficient (ICC). RESULTS: At baseline, the more observable domains of HRQL demonstrated greater agreement than the more subjective components. Cross-sectional point estimates of agreement were generally acceptable (ICC >0.70) for the EQ-5D Index and HUI3 summary scores when assessed >or=1 month after baseline. Agreement between change scores was generally poor to fair (ICC <0.60), but systematic bias was not observed for the indirect preference-based summary scores between baseline and 6 months. CONCLUSIONS: Results suggest that proxy assessments obtained 6 months after stroke are more reliable than those obtained within 2 to 3 weeks after stroke. Although proxy-assessed change scores for indirect preference-based summary scores of the EQ-5D and HUI3 provided suboptimal agreement with patient assessment, limited systematic bias may support their consideration as alternatives to missing data or statistical imputation. Further research into the validity and reliability of proxy assessments is suggested.