Retained Surgical Sponge Presenting Four Decades Later as a Rapidly Growing Soft Tissue Mass.

Retained surgical items continue to occur despite widespread implementation of prevention systems such as the surgical count, which has limited utility owing to its reliance on human performance. The most important risk factors for these events are poor communication in the operating room and inconsistent adherence to protocol. New technologies show efficacy in preventing retained surgical items and partially mitigating the poor reliability of the manual count. Additionally, efforts to address systemic and environmental sources of error have demonstrated success in reducing the incidence of retained surgical items. Here, we present the surprising case of a patient with a retained surgical sponge presenting as a soft tissue mass four decades after his surgery.

Ave Maria and Visions of Children: Atypical Charles Bonnet Syndrome or Two Coexisting Deafferentation Phenomena?

Charles Bonnet syndrome (CBS) refers to the experience of visual hallucinations in the context of visual impairment. The underlying pathology may be localized anywhere along the visual pathway from the eye itself to visual cortical centers. It is sometimes compared to phantom limb syndrome; both involve decreased sensory input, as in loss of a limb or declining vision, resulting in overactivity in areas of the brain controlling sensory perception. Definitive diagnostic criteria are still lacking and may vary by discipline. However, the following features are generally agreed upon: visual hallucinations, impaired vision, and intact cognition and insight. Psychiatric symptoms, cognitive decline, and hallucinations of other sensory modalities are often excluded, although this remains an area of debate. Certain non-classic cases of CBS have inspired the designation of atypical CBS, which encompasses a wide spectrum of sensory experiences and associated symptoms. Auditory hallucinations in the hearing-impaired, a well-described phenomenon thought to have a similar pathogenesis, share with CBS the important risk factor of increased age. In patients experiencing both types of hallucinations with deterioration in both sensory domains, the distinction between a CBS variant and two independent processes may not be straightforward. In addition to the ongoing diagnostic dilemma posed by multimodal hallucinations, these phenomena tend to be underreported by patients likely due to concern that they will be diagnosed with mental illness. Although many patients with this condition are indifferent to it, some suffer distress from their hallucinations and would benefit from recognition, reassurance, and in some cases correction of the underlying cause or pharmacologic treatment. Here we present the case of an elderly woman with a history of macular degeneration and chronic hearing loss who experienced complex auditory and visual hallucinations surrounding an episode of severe anxiety. We postulate that her anxiety acted as a precipitant to her hallucinatory experiences and may partially explain their abrupt onset in the absence of other clear pathologic processes. This case serves to reinforce CBS as a possible etiology of visual hallucinations in the elderly population, while also generating discussion of how to classify her particular set of symptoms.

Artery of Percheron Infarct: An Acute Diagnostic Challenge with a Spectrum of Clinical Presentations.

The artery of Percheron (AOP) is a variant of the paramedian thalamic vasculature that supplies blood to the medial aspect of the thalamus and the rostral midbrain. The presentation of an infarct in this territory varies widely and is often characterized by nonspecific neurological deficits, with altered mental status, decreased level of consciousness, and memory impairment being among the most common. AOP infarcts are often missed on initial computed tomography (CT) scan, and additional imaging is usually not done due to low suspicion for stroke in most cases. There have been an increasing number of reports of AOP infarction, illustrating the diversity of clinical presentations and the challenge this presents to clinicians in the acute setting. Lacking the classic signs of stroke, many of these patients experience a delay in recognition and treatment, with the majority of diagnoses occurring outside the tissue plasminogen activator (tPA) window. This case highlights the unusual presentation and diagnostic difficulty of a patient with an AOP infarct, and serves as a reminder to include thalamic pathology in patients presenting with vague neurological symptoms and no obvious signs of stroke.

Cognitive Decline in Adults Aged 65 and Older in Cumbayá, Quito, Ecuador: Prevalence and Risk Factors.

Objective To assess the prevalence of and risk factors for cognitive decline and dementia in individuals greater than 65 years of age in Cumbayá, Quito, Ecuador. Methods This is a cross-sectional observational study that was carried out in adults over age 65. The Mini Mental State Examination (MMSE), Ascertain Dementia Eight-Item Informant Questionnaire (AD8), and Mini Nutritional Assessment (MNA) were used to assess the cognitive status and nutritional habits of this population. Results A total of 144 patients (mean age 75.3 years, 77.1% female) participated in this study. Forty percent of patients had AD8 and MMSE scores consistent with cognitive impairment and possible dementia. Age (p < 0.01), lower educational level (p < 0.01), history of stroke (p < 0.01), history of intracerebral hemorrhage (p < 0.01), diabetes mellitus (p < 0.01), and malnutrition (p < 0.01) were statistically significant risk factors for cognitive impairment. Exercise was found to be protective against cognitive decline in our study group (p < 0.03). Gender, ethnicity, location, head trauma, Parkinson disease, hypercholesterolemia, myocardial infarction, thyroid disease, depression, anxiety, and family history of dementia were not found to be associated with cognitive decline in this population. Conclusions The prevalence of cognitive impairment and possible dementia is 18-21% at age 65 and 54-60% at age 85 in Cumbayá, Quito, Ecuador. The major risk factors for cognitive impairment in this population are age, low educational level, malnutrition, prior stroke, prior intracerebral hemorrhage, and diabetes. Protective factors for cognitive decline include exercise and possibly modest consumption of alcohol.

ATPase activity of the DEAD-box protein Dhh1 controls processing body formation.

Translational repression and mRNA degradation are critical mechanisms of posttranscriptional gene regulation that help cells respond to internal and external cues. In response to certain stress conditions, many mRNA decay factors are enriched in processing bodies (PBs), cellular structures involved in degradation and/or storage of mRNAs. Yet, how cells regulate assembly and disassembly of PBs remains poorly understood. Here, we show that in budding yeast, mutations in the DEAD-box ATPase Dhh1 that prevent ATP hydrolysis, or that affect the interaction between Dhh1 and Not1, the central scaffold of the CCR4-NOT complex and an activator of the Dhh1 ATPase, prevent PB disassembly in vivo. Intriguingly, this process can be recapitulated in vitro, since recombinant Dhh1 and RNA, in the presence of ATP, phase-separate into liquid droplets that rapidly dissolve upon addition of Not1. Our results identify the ATPase activity of Dhh1 as a critical regulator of PB formation.