Elevated systemic venous pressures as a possible pathology in prepubertal pediatric idiopathic intracranial hypertension.

BACKGROUND: Pediatric idiopathic intracranial hypertension (IIH) is a rare and challenging condition. As implied by the nomenclature, the etiologies remain unknown, and multiple etiologies are being investigated. In this study, we explored the potential role of increased systemic or cerebral venous pressure in the pathogenesis. METHOD: An observational cohort study following the STROBE guidelines, including prepubertal children with clinical symptoms and imaging findings consistent with IIH referred to the neurosurgical department, was conducted. The patients underwent a comprehensive diagnostic protocol, including MRI, continuous intracranial pressure (ICP) monitoring, and endovascular venography with venous pressure measurements. RESULTS: The study included 11 consecutive patients (six boys and five girls) with an average age of 2.3 years, and an average BMI of 18.4. Among these, one patient was found to have venous stenosis with a gradient; the other 10 patients presented with normal intracranial anatomy. All patients exhibited elevated venous pressures, with an average superior sagittal sinus pressure of 18.9 mmHg, average internal jugular vein pressure of 17.0 mmHg, and average central venous pressure of 15.9 mmHg. Daytime ICP averaged 12.9 mmHg, whereas nighttime ICP averaged 17.2 mmHg with either A- or B-waves in 10 of the 11 patients. Despite pathological ICP, only three patients had papilledema. CONCLUSIONS: All patients had an increased systemic venous pressure, indicating a possible pathological factor for prepubertal IIH. Additionally, our findings show that young children often only partly meet the Friedman criteria due to a lack of papilledema, emphasizing the need for pediatric-specific diagnostic criteria. Further large-scale studies are needed to confirm these findings and to explore the underlying reasons for this increase in venous pressure and potential new treatment avenues.

Mimickers of nervous system involvement among patients with Behçet's syndrome.

OBJECTIVES: We aimed to identify conditions mimicking nervous system involvement among patients with Behçet's syndrome (BS) and to determine clinical, laboratory and imaging findings that may help in the differential diagnosis. METHODS: We screened the charts of 500 consecutive BS patients to identify those who were referred to neurology at any time during their follow-up. The final diagnoses, presenting signs and symptoms, laboratory and imaging results were retrieved from patient charts. Patients who did not have a follow-up visit during the last 3 months were invited to the clinic. RESULTS: Among the 500 BS patients, 116 (23%) had been referred to neurology. Among these, 29 (5.8%) were diagnosed with typical central nervous system involvement of BS (NeuroBS). The type of NeuroBS was parenchymal involvement in 21 patients, cerebral venous sinus thrombosis in 7 patients, and both in 1 patient. 30 patients (6%) had other conditions related to the nervous system, 46 (9.2%) did not have a nervous system disorder, and their symptoms recovered spontaneously, and 11 (2.2%) were lost to follow-up without a definite diagnosis. Of the 30 BS patients who were diagnosed with another nervous system condition, 14 (46%) had primary headache syndromes, 6 (20%) had psychiatric disorders, 2 had entrapment neuropathy, and 1 each had epilepsy, glial tumor, multiple sclerosis, Meniere's disease, optic neuritis, neuroretinitis, steroid myopathy and polyneuropathy. CONCLUSION: Nervous system conditions other than NeuroBS are frequent among BS patients referred to neurology. Caution is required to avoid misdiagnosis of these patients as NeuroBS.

Comprehensive Review of Future Liver Remnant (FLR) Assessment and Hypertrophy Techniques Before Major Hepatectomy: How to Assess and Manage the FLR.

BACKGROUND: The regenerative capacities of the liver and improvements in surgical techniques have expanded the possibilities of resectability. Liver resection is often the only curative treatment for primary and secondary malignancies, despite the risk of post-hepatectomy liver failure (PHLF). This serious complication (with a 50% mortality rate) can be avoided by better assessment of liver volume and function of the future liver remnant (FLR). OBJECTIVE: The aim of this review was to understand and assess clinical, biological, and imaging predictors of PHLF risk, as well as the various hypertrophy techniques, to achieve an adequate FLR before hepatectomy. METHOD: We reviewed the state of the art in liver regeneration and FLR hypertrophy techniques. RESULTS: The use of new biological scores (such as the aspartate aminotransferase/platelet ratio index + albumin-bilirubin [APRI+ALBI] score), concurrent utilization of 99mTc-mebrofenin scintigraphy (HBS), or dynamic hepatocyte contrast-enhanced MRI (DHCE-MRI) for liver volumetry helps predict the risk of PHLF. Besides portal vein embolization, there are other FLR optimization techniques that have their indications in case of risk of failure (e.g., associating liver partition and portal vein ligation for staged hepatectomy, liver venous deprivation) or in specific situations (transarterial radioembolization). CONCLUSION: There is a need to standardize volumetry and function measurement techniques, as well as FLR hypertrophy techniques, to limit the risk of PHLF.

Neuro-Ophthalmic Manifestations of Carotid Cavernous Fistulas: A Systematic Review and Meta-Analysis.

Carotid-cavernous fistulas (CCFs) are pathologic, arteriovenous communications between the carotid artery and cavernous sinus. They cause various complex neuro-ophthalmic symptoms by shunting the flow of arterial blood into the venous system. In this study, a systematic review is conducted on the neuro-ophthalmic presentations associated with CCFs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were followed during the systematic review. We searched PubMed, Scopus, and Web of Science from inception to December 31, 2023. Articles written in English on patients with confirmed CCFs reporting clinical features, diagnostic modalities, treatment approaches, and outcomes were included. Abstracted data included demography, clinical presentations, venous flow dynamics, trauma history, investigative methodology, approaches to treatment, and outcomes. Overall, 33 studies with a total number of 403 patients were included. The mean age at presentation was 42.99 years for patients with direct CCFs and 55.88 years for those with indirect CCFs. Preponderance was observed in male patients with direct CCFs, constituting 51.56%, while females predominated in those with indirect CCFs, at 56.44%. The clinical symptoms in all patients with CCFs were proptosis in 58 cases (14.39%), conjunctival congestion in 29 patients (7.20%), diplopia in nine patients (2.23%), vision blurring in four patients (0.99%), eyelid swelling in five patients (1.24%), pain in the eye in three patients (0.74%), and an upper lid mass in one patient (0.25%). Endovascular treatments, including coil and Onyx embolization, have been effective in relieving clinical symptoms and arresting the progression of these symptoms. In conclusion, the common clinical features in CCFs usually underline proptosis, congestion, and diplopia, necessitating a comprehensive neuro-ophthalmological review. Prompt identification of the symptoms of blurred vision is crucial to avoid permanent damage. Lid swelling, ocular pain, and an upper lid mass are less common but equally essential presentations for comprehensive evaluation. The recognition of these variable presentations is essential not only for timely intervention but also for the improvement in patient outcomes, thus emphasizing the role of clinician awareness in managing CCF cases.

Lobular Capillary Hemangioma of the Buccal Mucosa: A Rare Presentation.

Hemangiomas are benign vascular tumours of the head and neck. Lobular capillary hemangioma (LCH) is a common, acquired proliferative reaction in vascular tissue. It has female predilection, and peak incidence occurs in adolescents and young adults. Histopathologically, it is characterised by nodular proliferation of capillary-sized vessels lined by endothelial cells with plump nuclei. The capillary lumen shows the presence of numerous erythrocytes. To distinguish this lesion from other vascular lesions, a precise diagnosis is required. The majority of oral hemangiomas will regress without any treatment. If these tumours continue into adulthood, it may lead to difficulty in speech and swallowing. This case report presents an atypical manifestation of LCH of the buccal mucosa in a 51-year-old male patient.

Pulmonary embolism incidence among patient admitted under psychiatry department: a case-control study.

Background: Pulmonary embolism (PE) is a serious and potentially life-threatening condition that requires prompt diagnosis and treatment. Identifying risk factors and diagnostic markers can aid in the early detection and management of this condition. Methods: This case-control study examined 10,077 patients admitted to Shenzhen Kangning Hospital's psychiatry facility in 2020. Among these, 65 patients were diagnosed with PE, including 50 new cases. After survival sampling for controls and age-and-gender matching, the study included 41 new PE cases and 41 age-and-gender-matched controls. Data on demographics, comorbidities, and medication use were extracted from electronic records. Conditional logistic regression analyses were performed to determine the association between each predictor and PE risk. Additionally, the sensitivity and specificity of the d-dimer diagnostic tool were assessed. Results: In univariable conditional logistic regression, active alcoholism was associated with a higher PE risk (OR=3.675, 95% CI 1.02-13.14, P=0.046). A history of physical restraint (OR=4.33, 95% CI 1.24-15.21, P=0.022) and chemical restraint (OR 4.67, 95% CI 1.34-16.24, p=0.015) also increased PE risk, as did benzodiazepine use (OR=3.33, 95% CI 1.34-8.30, P=0.010). Conversely, psychotropic medication before admission was associated with a lower risk of PE (OR=0.07, 95% CI 0.01-0.59, P=0.013). Stepwise multivariable forward conditional regression identified two subsets of psychiatric patients at higher risk of PE: new psychiatric cases without medication at admission who were chemically restrained, and cases without medication at admission who were started on antipsychotics and benzodiazepines. The d-dimer diagnostic tool, with an optimal threshold of 570 ng/ml determined by the Youden index (J statistic of 0.6098), showed a sensitivity of 73.17% and specificity of 87.80% for detecting PE, with an AUC of 0.833 (95% CI: 0.735-0.906). Conclusion: Our findings suggest that a history of restraint, alcoholism, and the use of antipsychotics and benzodiazepines are important predictors of PE in psychiatric inpatients. Conversely, psychotropic medications at admission may be linked to a lower PE risk. The d-dimer diagnostic tool shows good value for screening PE in psychiatric inpatients. These predictors and diagnostic markers could help clinicians identify high-risk patients and implement appropriate prevention strategies.

Unusual Evidence of Fat Embolism in the Subclavian Vein Detected by High-Intensity Transient Signals.

Fat emboli may occur in patients after traumatic fractures or orthopedic procedures; however, their clinical detection is a very rare finding. Here, we describe a 77-year-old female who was admitted to the emergency department with a fracture of the right humerus. We diagnosed fat embolism after an ultrasound of the right subclavian vein. The embolism was detected by high-intensity transient signals present on the spectral Doppler. While these signals are well known for microembolization in transcranial Doppler, to our knowledge this is the first case report in the medical literature to observe and describe high-intensity transient signals seen in the upper extremities by spectral Doppler. Although it is unusual to detect a fat embolism in transit, we believe clinicians should be aware of this finding, particularly when evaluating high-risk patients.

Efficacy and safety of hyaluronic-polidocanol foam in sclerotherapy for head and neck venous malformations.

Background: Foam sclerotherapy is currently the first-line treatment for venous malformations (VMs). Hyaluronic acid-polidocanol (HA-POL) foam has been used in the treatment of head and neck VMs recently; however, its clinical efficacy and safety have yet to be further evaluated, and the impact of age and other related factors on its safety is still unclear. Objective: To assess the efficacy and safety of HA-POL foam in the treatment of head and neck VMs. Methods and materials: We performed a single-center retrospective review of all patients with VMs involving the head and neck region undergoing HA-POL foam sclerotherapy from February 2015 to February 2022 in the Oral and Maxillofacial Surgery Department of Qilu Hospital Shandong University. Patients' medical records were collected and all patients enrolled were followed up for 1-6 months (group 1), part of them were followed up for 3-9 years (group 2). Results: A total of 223 patients with head and neck VMs were enrolled in the study, with 36 patients who were followed for 3-9 years. Total response rate in group 1 was 96.41% (n = 215), of which 30.94% (n = 69) of the patients met the criteria of "resolution," and 65.47% (n = 146) of the patients had "significant improvement." In group 2, the total response rate was 72.22% (n = 26), of which the rates of the patients met the criteria of "resolution" and patients had "significant improvement" were all 36.11% (n = 13)0.144 (64.57%) patients experienced complications like localized swelling, pain and fever, and no serious complications occurred. The risk of developing complications after treatment was independent of age, and was weakly associated with the dose of HA-POL foam. Conclusion: The HA-POL foam sclerotherapy is safe and effective in the treatment of head and neck VMs.

May-Thurner syndrome managed with catheter-directed thrombolysis and stent placement: A cases report.

Chronic compression of the left common iliac vein (CIV) by the right common iliac artery (CIA) or May-Thurner syndrome is rare and could be challenging to diagnose. The phenomenon results in chronic left lower extremity vein thrombosis. In this report, we present a 33-year-old female with pain and swelling in her left inner thigh for 2 days. She denied any systemic signs or any remarkable past medical history. Doppler ultrasonography revealed large blood clots extending from the left femoral and great saphenous veins to the upper part of the external iliac vein, causing a nearly complete obstruction. CT venography showed compression of the left CIV near the confluence by the right CIA and the lumbar vertebrae L4. She was managed by catheter-directed thrombolysis with alteplase via a superior vena cava catheter. Subsequently, a left CIV self-expanding stent was successfully placed. Follow-up demonstrated a positive outcome without any complications.

Changes after sterile inflammation caused by trabectedin infusion from central venous port: A case report.

Trabectedin is an antineoplastic drug used to treat soft tissue sarcomas. Trabectedin is mainly infused from the central venous port (CVP) because trabectedin leakage causes serious skin and soft tissue complications. Characteristic sterile inflammation has recently been reported after infusion of trabectedin from the CVP. Here, we report a case of sterile inflammation along a tunneled catheter pathway after trabectedin infusion from the CVP, with residual postinflammatory changes even after CVP removal. A 57-year-old man with myxoid liposarcoma developed skin erythema, swelling, and induration along a tunneled catheter pathway of the CVP after 16 cycles of trabectedin infusion through the CVP. The patient was diagnosed with sterile inflammation because various tests were negative for infection. The CVP was removed because the increasing injection resistance made trabectedin infusion difficult. The catheter firmly adhered to the surrounding tissue during removal. The induration and pigmentation along the catheter persisted for 4 months after CVP removal.

Best Practices for Optimizing Patients Undergoing Surgical Procedures to Prevent Postoperative Venous Thromboembolism: A Quality Improvement Project.

Introduction Current studies suggest that both chemical and mechanical venous thromboembolism (VTE) prophylaxis is underused, which is concerning due to the potential lethality of VTEs. The Caprini risk score is a preoperative VTE risk assessment that determines a patient's risk of enduring a VTE. The objective of this study was to examine postoperative cases of VTE to determine if accurate VTE risk stratification was performed and whether appropriate VTE prophylaxis was administered. Methods A retrospective analysis was conducted on 23 reported cases of VTE that occurred at a Central Florida hospital from April 1, 2021, to March 31, 2022. Relevant demographic and medical information was gathered from each patient chart to calculate an individual Caprini risk score and determine the type of chemical VTE prophylaxis that was received. Results Out of 23 reported cases of VTE in surgical patients, 17 were ultimately determined to have suffered VTE associated with their hospitalization and surgery. Thirteen out of 17 (76%) received appropriate perioperative chemical deep vein thrombosis (DVT) prophylaxis based on the calculated Caprini risk score and corresponding recommendations. Four out of 17 (24%) were determined to have received insufficient perioperative chemical DVT prophylaxis. Conclusion Consistent utilization of a DVT/pulmonary embolism (PE) risk stratification tool, such as the Caprini risk score calculator, is essential in the prevention of postoperative VTE. Hospitals can improve the utilization of such a tool and thereby reduce the number of embolic events by making it more visible and accessible to the overseeing provider in the electronic medical record (EMR).

Venous Excess Ultrasound for Fluid Assessment in Complex Cardiac Patients With Acute Kidney Injury.

INTRODUCTION: The introduction of point-of-care ultrasound (POCUS) into clinical practice has revolutionized bedside hemodynamic assessment in recent years. POCUS has expanded its utility to include evaluating and grading venous congestion through Doppler analysis of venous blood flow. This innovative technique, VExUS (venous excess ultrasound), comprehensively evaluates venous congestion across multiple sites, including the inferior vena cava (IVC), hepatic vein, portal vein, and intrarenal vasculature. The aim of the current study was to determine whether venous excess ultrasound can help guide fluid therapy in complex patients with acute kidney injury (AKI) in addition to the standard physical examination and imaging. METHODS: Our current study shows instructive 18 clinical adult cases (enrolled between January 2024 and May 2024) to determine whether venous excess ultrasound can help guide fluid therapy in complex cardiac patients with acute kidney injury, in addition to the standard physical examination and imaging. RESULTS: VExUS was pivotal in guiding fluid therapy in all complex patients with AKI and suspected right ventricular dysfunction. By integrating VExUS findings with clinical data and cardiac ultrasound results, clinicians were able to make patient-favouring decisions regarding fluid management, diuresis, and vasopressor therapy, addressing critical aspects of conditions such as septic shock, heart failure, and acute kidney injury. CONCLUSIONS: In our study of VExUS in sick patients with AKI, we concluded that VExUS proved to be a valuable tool for fluid assessment and management. By providing real-time visualization of venous congestion, VExUS allowed for more precise and individualized fluid management strategies. This led to improved decision-making regarding fluid administration and removal, helping to prevent both fluid overload and hypovolemia. Consequently, the use of VExUS contributed to better clinical outcomes in patients with AKI, demonstrating its potential as a critical component in the management of fluid balance in this vulnerable patient population.

Serum albumin, genetic susceptibility, and risk of venous thromboembolism.

Background: Previous research on the association between serum albumin (ALB) and venous thromboembolism (VTE) has produced inconclusive results. The polygenic risk score is constructed from a set of independent risk variants associated with a disorder, enabling the identification of a larger fraction of the population at comparable or greater disease risk. It is still unknown whether ALB and genetic factors jointly contribute to the incidence of VTE. Objectives: The present study aimed to explore ALB, genetic susceptibility, and the risk of VTE. Methods: The present investigation was an analysis of prospectively collected data from UK Biobank, a population-based, longitudinal cohort. Cox proportional models were used to calculate hazard ratios and 95% CIs for VTE. The Kaplan-Meier curve was utilized to visualize the cumulative risk of VTE according to different serum ALB levels, and the restricted cubic spline model was leveraged to explore the exposure-response relationship among ALB levels and VTE risk. Results: During median follow-up of 13.5 years, 11,502 cases with VTE were diagnosed among 417,113 participants in the UK Biobank. The lower ALB levels were associated with a higher risk for VTE. Individuals with both a high genetic risk and lowest ALB level had the highest risk of VTE (hazard ratio, 3.89; 95% CI, 3.41-4.43), compared with those with low genetic risk and highest ALB level. The positive joint effects of low ALB and polygenic risk score increased the risk of VTE in individuals with high genetic risk. This study excluded non-European patients and primarily focused on the European population, which may limit the generalizability of the findings. Conclusion: Low serum ALB levels were linked to an increased risk of VTE, which was in accordance with a linear dose-response relationship. There was a positive additive effect of ALB and genetic susceptibility on the risk of VTE. ALB could serve as a biomarker for predicting the risk of VTE.

Comparison of Metabolic, Ionic, and Electrolyte Responses to Exhaustive Low-Load Strength Training With and Without Blood Flow Restriction and High-Load Resistance Training.

Low-load blood-flow-restriction resistance training (LL-BFR-RT) is gaining popularity, but its physiological effects remain unclear. This study aimed to compare LL-BFR-RT with low-load resistance exercise (LL-RT) and high-load resistance exercise (HL-RT) on metabolism, electrolytes, and ions in the lower extremities by invasive catheter measurements, which are crucial for risk assessment. Ten healthy men (27.6 ± 6.4 years) completed three trials of knee-extensor exercises with LL-RT (30% 1RM), LL-BFR-RT (30% 1RM, 50% limb occlusion pressure), and HL-RT (75% 1RM). The exercise protocol consisted of four sets to voluntary muscle failure with 1 min of rest between sets. Blood gas analysis was collected before, during, and after each trial through intravenous catheters at the exercising leg. LL-BFR-RT had lower total workload (1274 ± 237 kg, mean ± SD) compared to LL-RT (1745 ± 604 kg), and HL-RT (1847 ± 367 kg, p < 0.01), with no difference between LL-RT and HL-RT. Pain perception did not differ significantly. Exercise-induced drop in oxygen partial pressure, lactate accumulation and electrolyte shifts (with increased [K+]) occurred during under all conditions (p < 0.001). Creatine kinase and lactate dehydrogenase increased significantly 24- and 48-h postexercise under all three conditions (p < 0.001). This study, using invasive catheter measurements, found no significant differences in metabolic, ionic, and electrolyte responses among LL-BFR-RT, LL-RT, and HL-RT when exercised to voluntary muscular failure. LL-BFR-RT reduced time to failure without specific physiological responses.

Sex differences in the clinical manifestations and treatment outcomes in a large cohort of spontaneous intracranial hypotension.

OBJECTIVE: To determine sex differences in clinical profiles and treatment outcomes in patients with spontaneous intracranial hypotension. BACKGROUND: Spontaneous intracranial hypotension is associated with considerable functional disability and potentially fatal complications, and it is uncertain whether males and females should be managed differently. METHODS: This was a cohort study of consecutive patients with spontaneous intracranial hypotension enrolled from a medical center. Medical records and imaging findings were reviewed. The outcome of treatment responses to epidural blood patches and risks of subdural hematoma were measured. RESULTS: In total, 442 patients with spontaneous intracranial hypotension (165 males, 277 females) were included in the analysis. Males were more likely to have a delayed (>30 days) initial presentation than females (32.1% [53/165] vs. 19.9% [55/277], p = 0.004), and males were less likely to have nausea (55.8% [92/165] vs. 67.1% [186/277], p = 0.016), vomiting (43.0% [71/165] vs. 54.2% [150/277], p = 0.024), photophobia (9.7% [16/165] vs. 17.0% [47/277], p = 0.034), and tinnitus (26.7% [44/165] vs. 39.7% [110/277], p = 0.005) compared with females despite comparable radiologic findings. Among the 374 patients treated with epidural blood patches, males were more likely to be nonresponders to the first epidural blood patch (58.0% [80/138] vs. 39.0% [92/236], OR = 2.2, 95% CI = 1.4-3.3, p < 0.001). Males were at a higher risk of having subdural hematoma (29.7% [49/165] vs. 10.8% [30/277], OR = 3.5, 95% CI = 2.1-5.8, p < 0.001). Among patients with subdural hematoma, males had greater thickness (12.8 ± 4.3 vs. 8.1 ± 5.9 mm, p < 0.001) and were more likely to receive surgical drainage (55.1% [27/49] vs. 10.0% [3/30], OR = 11.0, 95% CI = 3.0-41.3, p < 0.001) than females. CONCLUSION: In the present study, spontaneous intracranial hypotension in males was characterized by a delayed presentation, poorer response to the first epidural blood patch, and a higher risk of subdural hematoma. Caution should be exercised in the management of males with spontaneous intracranial hypotension. The generalizability of the findings needs to be further confirmed.

Low pneumoperitoneum pressure on venous thromboembolism in laparoscopic colorectal cancer surgery: A randomized controlled study.

INTRODUCTION: Venous thromboembolism (VTE) poses a significant risk in colorectal cancer surgeries due to hypercoagulability and the anatomical challenges of the pelvic cavity. With the advancement of minimally invasive techniques, intraoperative strategies for preventing VTE may prove to be effective. This study explores the effects of intraoperative pneumoperitoneum pressures on VTE incidence following colorectal cancer surgeries. METHODS: This single center parallel randomized controlled double-blind, trial involved 302 patients undergoing elective laparoscopic or robotic colorectal surgery. Patients were randomized to either a standard pneumoperitoneum pressure group (SP: 15 mmHg) or a low-pressure group (LP: 10 mmHg). Primary outcomes measured were the incidence of VTE, including symptomatic and asymptomatic DVT and PE. Secondary outcomes included postoperative D-dimer levels, surgery duration, blood loss, surgeon satisfaction, and oncological quality. RESULTS: Out of 302 randomized patients, 275 were evaluable post exclusions, with 138 in the SP group and 137 in the LP group. The incidence of VTE was 10.9 % in the SP and 13.9 % in the LP group, with no significant difference between the two (P = 0.450). Secondary outcomes such as D-dimer levels, surgery duration, and blood loss showed no significant differences between two groups. Surgeon satisfaction and oncological outcomes were similarly comparable. CONCLUSIONS: The trial demonstrated no significant difference in the incidence of VTE between standard and low pneumoperitoneum pressures. This suggests that lower pressures may not necessarily provide a benefit in reducing postoperative VTE in colorectal cancer surgeries.

TO INFORM OR NOT TO INFORM about venous thromboembolisms - A qualitative study on communication between healthcare professionals and patients with lung cancer.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of death among cancer patients. Despite this, studies show that patients with cancer feel inadequately informed about the VTE risk and symptoms, which may impede their ability to recognise symptoms and react promptly. Patients with lung cancer are especially vulnerable due to a high relative risk of developing VTE combined with a high prevalence of low health literacy. This study aimed to explore the VTE information needs of lung cancer patients and how patients and healthcare professionals (HCPs) communicate about VTE. MATERIAL AND METHODS: Data was collected via semi-structured interviews with patients with lung cancer and HCPs. All participants (n = 20) were recruited from an oncological department. The analysis was performed in an inductive manner using a Ricoeur inspired strategy. FINDINGS: Patients had varying information needs regarding VTE, but HCPs did not routinely communicate about VTE, as the topic tended to be lowly prioritised. HCPs communicated about VTE when patients expressed a need or presented symptoms of VTE. HCPs expressed concerns about adding to patient's emotional burden by informing about VTE, while some patients emphasised the importance of being mentally prepared for potential complications. CONCLUSION: The study demonstrates the challenging balance HCPs must maintain between adequately communicating about VTE and not causing undue psychological distress. However, given patient's often limited awareness of VTE, the responsibility to initiate communication about VTE must fall on the HCPs.

Dural arteriovenous fistulae in a 6-year-old girl with trisomy 21 and congenital heart disease.

Dural arteriovenous fistula (DAVF) represents a pathological group of intracranial shunts arising from the dural artery to venous sinus and veins. Childhood-onset DAVF is generally considered to be poor in prognosis, whereas only limited information is available for the onset and long-term outcomes. We herein report a Japanese girl with trisomy 21, large ventricular septal defects, and pulmonary vein stenosis, for which a transcatheter stent had been placed after birth. At age 6 years, she developed bacterial meningitis due to S. pneumoniae, leading to the diagnosis of venous sinus thrombosis and multiple intracranial shunts. Cerebral angiography identified multiple shunts arising from the middle meningeal arteries to the superior sagittal sinus and a concurrent reflux to cortical vein. Endovascular embolization successfully occluded the shunts without neurovascular complications over 24 months. This report first demonstrates the favorable outcome of DAVF in a pediatric patient with trisomy 21 after the catheter intervention. For children at a risk for intracranial thrombosis, preemptive neurovascular evaluation and transcatheter intervention provide a chance of early diagnosis of DAVF to improve their survival and neurologic outcome.

The changing face of cerebral venous sinus thrombosis - emerging new causes and treatments.

Cerebral venous sinus thrombosis (CVST) is an uncommon site of venous thromboembolism. CVST more commonly affects younger people and women, in stark contrast to other forms of venous thrombosis where incidence increases with age and overall affects men. Traditional risk factors for the development of CVST include endogenous and exogenous estrogen (combined oral contraceptives and pregnancy and the puerperium), thrombophilias and rare haematologic disorders. New and emerging risk factors include obesity, polycystic ovary syndrome, COVID-19 infection, and vaccine-induced thrombocytopenia and thrombosis (VITT) and VITT-like disorders. Management centres around anticoagulation, managing the underlying cause, and consideration of invasive measures including endovascular thrombolysis and/or thrombectomy and craniectomy for severe cases. This review discusses the emerging risk factors and their identification, evidence for treatment including the use of direct oral anticoagulants, and the role of invasive management options.