Association of Timing With Postoperative Complications in the Management of Open Distal Radius Fractures.

BACKGROUND: This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. METHODS: Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. RESULTS: One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. CONCLUSION: Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. LEVEL OF EVIDENCE: Level IV.

Dentate Gyrus Microstructure Is Associated With Resilience After Exposure to Maternal Stress Across Two Human Cohorts.

BACKGROUND: Maternal stress (MS) is a well-documented risk factor for impaired emotional development in offspring. Rodent models implicate the dentate gyrus (DG) of the hippocampus in the effects of MS on offspring depressive-like behaviors, but mechanisms in humans remain unclear. Here, we tested whether MS was associated with depressive symptoms and DG micro- and macrostructural alterations in offspring across 2 independent cohorts. METHODS: We analyzed DG diffusion tensor imaging-derived mean diffusivity (DG-MD) and volume in a three-generation family risk for depression study (TGS; n = 69, mean age = 35.0 years) and in the Adolescent Brain Cognitive Development (ABCD) Study (n = 5196, mean age = 9.9 years) using generalized estimating equation models and mediation analysis. MS was assessed by the Parenting Stress Index (TGS) and a measure compiled from the Adult Response Survey from the ABCD Study. The Patient Health Questionnaire-9 and rumination scales (TGS) and the Child Behavior Checklist (ABCD Study) measured offspring depressive symptoms at follow-up. The Schedule for Affective Disorders and Schizophrenia-Lifetime interview was used to assign depression diagnoses. RESULTS: Across cohorts, MS was associated with future symptoms and higher DG-MD (indicating disrupted microstructure) in offspring. Higher DG-MD was associated with higher symptom scores measured 5 years (in the TGS) and 1 year (in the ABCD Study) after magnetic resonance imaging. In the ABCD Study, DG-MD was increased in high-MS offspring who had depressive symptoms at follow-up, but not in offspring who remained resilient or whose mother had low MS. CONCLUSIONS: Converging results across 2 independent samples extend previous rodent studies and suggest a role for the DG in exposure to MS and offspring depression.

A Clinical Perspective on Arsenic Exposure and Development of Atherosclerotic Cardiovascular Disease.

Cardiovascular risk has traditionally been defined by modifiable and non-modifiable risk factors, such as tobacco use, hyperlipidemia, and family history. However, chemicals and pollutants may also play a role in cardiovascular disease (CVD) risk. Arsenic is a naturally occurring element that is widely distributed in the Earth's crust. Inorganic arsenic (iAs) has been implicated in the pathogenesis of atherosclerosis, with chronic high-dose exposure to iAs (> 100 µg/L) being linked to CVD; however, whether low-to-moderate dose exposures of iAs (< 100 µg/L) are associated with the development of CVD is unclear. Due to limitations of the existing literature, it is difficult to define a threshold for iAs toxicity. Studies demonstrate that the effect of iAs on CVD is far more complex with influences from several factors, including diet, genetics, metabolism, and traditional risk factors such as hypertension and smoking. In this article, we review the existing data of low-to-moderate dose iAs exposure and its effect on CVD, along with highlighting the potential mechanisms of action.

Initial Experience with the PONTiS Tendon Repair System in Traumatic Upper Extremity Injuries.

BACKGROUND: Tendon injuries of the upper extremity remain a common surgical condition requiring prompt intervention. The authors review their initial experience with the PONTiS flexor tendon repair system, a knotless, multifilament, stainless steel crimp system. METHODS: Consecutive patients undergoing repair by plastic and orthopedic surgeons with the PONTiS system were reviewed for the period from 2015 to 2017. Multivariate risk and Kaplan-Meier survival analyses were performed to assess risk factors associated with complications. RESULTS: Eighty-one patients, with a mean follow-up of 75 days (range, 0 to 33 months), were identified. The most common demographics showed patients were right-handed (82.9 percent), male (71.4 percent), and laborers (35.7 percent) and sustained laceration injuries (77.1 percent) at zone 2 (27.2 percent). There were, on average, 3.7 tendon injuries per patient. Associated injuries included fractures (21.4 percent), arterial injuries (24.3 percent), and nerve injuries (61.4 percent). Thirteen patients (16.0 percent) developed complications, including adhesions/contracture ( n = 4), rupture ( n = 2), flap ischemia ( n = 2), arterial thrombosis ( n = 1), wound dehiscence ( n = 1), tendon lag ( n = 1), and erosion of the PONTiS system through soft-tissue grafts ( n = 2). Multivariate analysis identified poor soft-tissue coverage (OR, 9.990; p = 0.043) and zone 2 involvement (OR, 7.936; p = 0.016) as risk factors, while epitendinous repairs (OR, 0.096; p = 0.010) were protective against complications. CONCLUSIONS: The PONTiS flexor tendon repair system is rapid, simple to deploy, and advantageous, especially in multiple traumatic tendon injuries. In comparison to traditional suture repair, it has a comparable overall complication profile but superior rupture and tenolysis rates. The authors advise using it with caution in cases with poor soft-tissue coverage to minimize risks of extrusion, and they strongly recommend the use of epitendinous sutures concurrently to limit complications.

Automated Multiclass Artifact Detection in Diffusion MRI Volumes via 3D Residual Squeeze-and-Excitation Convolutional Neural Networks.

Diffusion MRI (dMRI) is widely used to investigate neuronal and structural development of brain. dMRI data is often contaminated with various types of artifacts. Hence, artifact type identification in dMRI volumes is an essential pre-processing step prior to carrying out any further analysis. Manual artifact identification amongst a large pool of dMRI data is a highly labor-intensive task. Previous attempts at automating this process are often limited to a binary classification ("poor" vs. "good" quality) of the dMRI volumes or focus on detecting a single type of artifact (e.g., motion, Eddy currents, etc.). In this work, we propose a deep learning-based automated multiclass artifact classifier for dMRI volumes. Our proposed framework operates in 2 steps. In the first step, the model predicts labels associated with 3D mutually exclusive collectively exhaustive (MECE) sub-volumes or "slabs" extracted from whole dMRI volumes. In the second step, through a voting process, the model outputs the artifact class present in the whole volume under investigation. We used two different datasets for training and evaluating our model. Specifically, we utilized 2,494 poor-quality dMRI volumes from the Adolescent Brain Cognitive Development (ABCD) and 4,226 from the Healthy Brain Network (HBN) dataset. Our results demonstrate accurate multiclass volume-level main artifact type prediction with 96.61 and 97.52% average accuracies on the ABCD and HBN test sets, respectively. Finally, in order to demonstrate the effectiveness of the proposed framework in dMRI pre-processing pipelines, we conducted a proof-of-concept dMRI analysis exploring the relationship between whole-brain fractional anisotropy (FA) and participant age, to test whether the use of our model improves the brain-age association.

Baseline cardiometabolic profiles and SARS-CoV-2 infection in the UK Biobank.

BACKGROUND: SARS-CoV-2 is a rapidly spreading coronavirus responsible for the Covid-19 pandemic, which is characterized by severe respiratory infection. Many factors have been identified as risk factors for SARS-CoV-2, with much early attention being paid to body mass index (BMI), which is a well-known cardiometabolic risk factor. OBJECTIVE: This study seeks to examine the impact of additional baseline cardiometabolic risk factors including high density lipoprotein-cholesterol (HDL-C), low density lipoprotein-cholesterol (LDL-C), Apolipoprotein A-I (ApoA-I), Apolipoprotein B (ApoB), triglycerides, hemoglobin A1c (HbA1c) and diabetes on the odds of testing positive for SARS-CoV-2 in UK Biobank (UKB) study participants. METHODS: We examined the effect of BMI, lipid profiles, diabetes and alcohol intake on the odds of testing positive for SARS-Cov-2 among 9,005 UKB participants tested for SARS-CoV-2 from March 16 through July 14, 2020. Odds ratios and 95% confidence intervals were computed using logistic regression adjusted for age, sex and ancestry. RESULTS: Higher BMI, Type II diabetes and HbA1c were associated with increased SARS-CoV-2 odds (p < 0.05) while HDL-C and ApoA-I were associated with decreased odds (p < 0.001). Though the effect of BMI, Type II diabetes and HbA1c were eliminated when HDL-C was controlled, the effect of HDL-C remained significant when BMI was controlled for. LDL-C, ApoB and triglyceride levels were not found to be significantly associated with increased odds. CONCLUSION: Elevated HDL-C and ApoA-I levels were associated with reduced odds of testing positive for SARS-CoV-2, while higher BMI, type II diabetes and HbA1c were associated with increased odds. The effects of BMI, type II diabetes and HbA1c levels were no longer significant after controlling for HDL-C, suggesting that these effects may be mediated in part through regulation of HDL-C levels. In summary, our study suggests that baseline HDL-C level may be useful for stratifying SARS-CoV-2 infection risk and corroborates the emerging picture that HDL-C may confer protection against sepsis in general and SARS-CoV-2 in particular.

Diagnostic challenges in neoplastic meningitis presenting as intracranial hypertension.

A diagnosis of idiopathic intracranial hypertension should be considered only after careful exclusion of all possible aetiologies. We report a case of neoplastic meningitis presenting as intracranial hypertension with inconclusive repeated cerebrospinal fluid (CSF) cytology and MRI of brain, emphasising the importance of meticulous CSF analysis and role of early whole-body PET-CT scan for diagnosis of systemic malignancy.

Progressive Myoclonic Epilepsy'-like presentation of Cerebrotendinous Xanthomatosis in an Indian Family with A Novel C.646+1G>A Splice Site Mutation.

Cerebrotendinous Xanthomatosis (CTX) is a rare autosomal-recessive inborn disorder of bile acid metabolism due to mutations in the CYP27A1 gene. It presents with a diverse range of neurological and non-neurological symptoms. We present a case of CTX with a progressive myoclonic epilepsy (PME) like phenotype and a family history of CTX. The proband had a generalized epilepsy with prominent myoclonus. He also had intellectual decline, ataxia, bipyramidal dysfunction and peripheral neuropathy. The younger sibling had a milder generalized epilepsy without myoclonus along with behavioral issues, ataxia, neuropathy, and prominent tendon xanthomas. Both the siblings had developmental cataracts. MRI Brain of both had dentate hyperintensities with cerebellar atrophy. The proband's EEG showed severe background slowing with multifocal interictal discharges. Targeted gene of analysis proband revealed a novel homozygous 5' splice site variation in intron 3 of the CYP27A1 gene. We present a novel phenotype and genotype of CTX presenting with a syndrome of myoclonic epilepsy. This is the first PME-like presentation of CTX to the best of our knowledge. CTX may present with a PME-like clinical phenotype and should be considered as a treatable cause within the differential diagnostic evluation of syndromic epilepsies involving an atypical familial myoclonic epilepsy.

Baseline Cardiometabolic Profiles and SARS-CoV-2 Infection in the UK Biobank.

BACKGROUND: SARS-CoV-2 is a rapidly spreading coronavirus with a high incidence of severe upper respiratory infection that first presented in Wuhan, China in December 2019. Many factors have been identified as risk factors for SARS-CoV-2, with much attention being paid to body mass index (BMI). Little investigation has been done to investigate dysregulation of lipid profiles and diabetes, which are often comorbid in high BMI patients. OBJECTIVE: This study seeks to describe the impact of BMI, HDL, LDL, ApoA, ApoB, triglycerides, hemoglobin A1c (HbA1c), diabetes, alcohol and red wine intake on the odds of testing positive for SARS-CoV-2 in UK Biobank (UKB) study participants. METHODS: We examined the effect of BMI, lipid profiles, diabetes and alcohol intake on the odds of testing positive for SARS-Cov-2 among 9,005 UKB participants tested for SARS-CoV-2 from March 16 through July 14, 2020. Odds ratios and 95% confidence intervals were computed using logistic regression adjusted for age, sex and ancestry. RESULTS: Higher BMI, Type II diabetes and HbA1c were associated with increased SARS-CoV-2 odds (p < 0.05) while HDL and ApoA were associated with decreased odds (p < 0.001). Though the effect of BMI, Type II diabetes and HbA1c were eliminated when HDL was controlled, the effect of HDL remained significant when BMI was controlled for. Additionally, red wine intake was associated with reduced odds of testing positive for SARS-CoV-2 (p < 0.05). LDL, ApoB and triglyceride levels were not found to be significantly associated with increased odds. CONCLUSION: Elevated HDL and ApoA levels and alcohol intake, specifically red wine intake, were associated with reduced odds of testing positive for SARS-CoV-2, while higher BMI, type II diabetes and HbA1c were associated with increased odds. The effects of alcohol, BMI, type II diabetes and HbA1c levels were no longer significant after controlling for HDL, suggesting that these effects may be mediated in part through regulation of HDL levels. In summary, our study corroborates the emerging picture that high HDL levels may confer protection against SARS-CoV-2. HIGHLIGHTS: Higher baseline HDL levels were associated with reduced odds of testing positive for SARS-CoV-2.BMI, Type II diabetes and hemoglobin A1C levels were associated with elevated odds of testing positive for SARS-CoV-2, but this effect was abrogated when controlling for HDL.Red wine intake was associated with reduced odds of testing positive for SARS-CoV-2, although this effect may in part be moderated by HDL.Baseline LDL and Triglyceride levels were not associated with increased odds of testing positive for SARS-CoV-2.

Adult-Onset Isolated Hemichorea Revealing Iatrogenic Hypoparathyroidism and Bilateral Basal Ganglia Calcification.

Isolated hemichorea (HC) in adults has a relatively restricted differential diagnosis including stroke of contralateral basal ganglia nuclei, nonketotic hyperglycemia, and basal ganglia toxoplasmosis in HIV infection. Hypoparathyroidism-related basal ganglia calcification can potentially cause neurological problems, including movement disorders, that are usually bilateral in keeping with bilateral symmetric lesions. We report a patient with video-documented isolated, adult-onset HC due to iatrogenic hypoparathyroidism and bilateral basal ganglia calcification. A 47-year-old woman presented with isolated adult-onset HC of 2 years' duration as the presenting and only neurological feature of hypoparathyroidism and bilateral extensive basal ganglia calcification, 20 years after thyroidectomy-induced hypoparathyroidism. Significant improvement in the unilateral hyperkinesia was noted after correction of hypocalcemia and hypoparathyroidism at 3 months. Isolated HC in adults is a rare presenting feature of hypoparathyroidism with bilateral basal ganglia calcification and is treatable with correction of the underlying metabolic abnormality. In all cases with a movement disorder and brain calcification, hypoparathyroidism should be actively sought as this treatable condition must not be missed.

Rare and Treatable Cause of Early-Onset Refractory Absence Seizures.

Glut-1 transporter deficiency syndrome (GLUT1-DS) is a rare disorder caused by the mutation in SLC2A1 gene, which results in impaired glucose transport into the brain. It has a broad spectrum of phenotypic presentation ranging from cognitive decline, microcephaly, and refractory seizures to complex movement disorder. Recognition of this disorder is necessary as it is refractory to antiepileptic drugs (AEDs) and responds significantly to ketogenic diet. We report a case of 7-year-old girl who presented with paroxysmal eye movements in infancy with early-onset absence epilepsy (EOAE), which worsened in early morning and on fasting and was found to be refractory to four AEDs. She had mild developmental delay and subtle ataxia. Cerebrospinal fluid showed hypoglycorrhachia, and molecular analysis identified deletion in exon 4 of SLC2A1 gene (p.leu169del), thus confirming GLUT1-DS. She had a near-complete seizure control on ketogenic diet. Thus, GLUT1-DS should be suspected in all cases of refractory generalized seizures specially EOAE, especially if it worsens on fasting, is associated with development delay, positive family history, or paroxysmal movement disorder.

The Impact of Mesh Reinforcement with Components Separation for Abdominal Wall Reconstruction.

The goal in abdominal wall reconstruction (AWR) is to minimize morbidity and prevent hernia recurrence. Components separation and mesh reconstruction are two options, however, with advantages and disadvantages. The purpose of this review was to investigate outcomes in patients with abdominal wall hernia undergoing primary closure with component separation (CS) versus CS with acellular dermal matrix (ADM) reinforcement (CS + mesh). Medical records of consecutive patients who underwent abdominal wall reconstruction using CS with or without ADM reinforcement were retrospectively reviewed. Primary fascial closure was achieved in all patients. ADM reinforcement when used was performed using the underlay technique. Reconstructive technique and postoperative complications including delayed healing, skin necrosis, fistula, seroma, hematoma and surgical site infection, recurrence, and reoperation were recorded. Comparisons between the two groups were assessed. One hundred and seven patients were included (mean age, 55.7; 51.4% male; median follow-up 297 days). Twenty-six patients (24%) underwent CS alone; whereas 81 patients (76%) CS + mesh placement. Patient comorbidities, including smoking (26%), diabetes (20%), and hypertension (46%); body mass index (mean 32.3 ± 7.6); and albumin level on the day of surgery (mean 3.4 ± 0.5 mg/dL) were not significantly different between groups. Surgical site infection was significantly higher among CS + mesh patients (22.2%) versus CS only patients (3.9%) (P = 0.02). The recurrence rate of abdominal hernia was significantly lower in CS + mesh patients compared with CS only (14.8% vs 34.6%; P = 0.02). No significant differences in other postoperative complications were identified between the two groups. ADM reinforcement at the time of components separation is often selected in more complex, higher risk patients. Although the incidence of infection was higher in these patients, it was usually treated without mesh removal and recurrence rate was significantly lower when compared to CS alone.

The Role of Nitrates in the Management of Stable Ischemic Heart Disease: A Review of the Current Evidence and Guidelines.

Coronary artery disease is the leading cause of mortality in the United States and can result in significant morbidity. In particular, stable ischemic heart disease (SIHD) is a condition that affects nearly 9 million individuals in the United States alone, with substantial annual health care costs related to recurrent medical visits and chronic disease management. Nitrates form a cornerstone of SIHD management by reducing myocardial oxygen consumption and increasing exercise capacity by several mechanisms, including increasing epicardial blood flow through vasodilation and decreased vascular resistance, blunting coronary steal, and reducing preload. Yet the role of nitrates may be underappreciated in clinical practice and their utilization may be limited due to concerns of tolerance to treatment, a lack of randomized data validating their ability to prevent adverse cardiovascular events, and the pervasive use of percutaneous interventions without robust attempts at implementing optimal medical therapy. In this review, we discuss both the recent ACC/AHA/ACP/AATS/PCNA/SCAI/STS and European Society of Cardiology guidelines, with a particular focus on indications, contraindications, and future directions of nitrate therapy in SIHD.