A Narrative Review on 3-Dimensional Visualization Techniques in Neurosurgical Education, Simulation, and Planning.

BACKGROUND: High-fidelity visualization of anatomical organs is crucial for neurosurgical education, simulation, and planning. This becomes much more important for minimally invasive neurosurgical procedures. Realistic anatomical visualization can allow resident surgeons to learn visual cues and orient themselves with the complex 3-dimensional (3D) anatomy. Achieving full fidelity in 3D medical visualization is an active area of research; however, the prior reviews focus on the application area and lack the underlying technical principles. Accordingly, the present study attempts to bridge this gap by providing a narrative review of the techniques used for 3D visualization. METHODS: We conducted a literature review on 3D medical visualization technology from 2018 to 2023 using the PubMed and Google Scholar search engines. The cross-referenced manuscripts were extensively studied to find literature that discusses technology relevant to 3D medical visualization. We also compiled and ran software applications that were accessible to us in order to better understand them. RESULTS: We present the underlying fundamental technology used in 3D medical visualization in the context of neurosurgical education, simulation, and planning. Further, we discuss and categorize a few important applications based on the 3D visualization techniques they use. CONCLUSIONS: The visualization of virtual human organs has not yet achieved a level of realism close to reality. This gap is largely due to the interdisciplinary nature of this research, population diversity, and validation complexities. With the advancements in computational resources and automation of 3D visualization pipelines, next-gen applications may offer enhanced medical 3D visualization fidelity.

Pathophysiology, diagnosis, and herbal medicine-based therapeutic implication of rheumatoid arthritis: an overview.

Rheumatoid arthritis (RA) stands as an autoimmune disorder characterized by chronic joint inflammation, resulting in profound physiological alterations within the body. Affecting approximately 0.4-1.3% of the global population, this condition poses significant challenges as current therapeutic approaches primarily offer symptomatic relief, with the prospect of complete recovery remaining elusive. This review delves into the contemporary advancements in understanding the pathophysiology, diagnosis, and the therapeutic potential of herbal medicine in managing RA. Notably, early diagnosis during the initial stages emerges as the pivotal determinant for successful recovery post-treatment. Utilizing tools such as Magnetic Resonance Imaging (MRI), anti-citrullinated peptide antibody markers, and radiography proves crucial in pinpointing the diagnosis of RA with precision. Unveiling the intricate pathophysiological mechanisms of RA has paved the way for innovative therapeutic interventions, incorporating plant extracts and isolated phytoconstituents. In the realm of pharmacological therapy for RA, specific disease-modifying antirheumatic drugs have showcased commendable efficacy. However, this conventional approach is not without its drawbacks, as it is often associated with various side effects. The integration of methodological strategies, encompassing both pharmacological and plant-based herbal therapies, presents a promising avenue for achieving substantive recovery. This integrated approach not only addresses the symptoms but also strives to tackle the underlying causes of RA, fostering a more comprehensive and sustainable path towards healing.

Rituximab Used for the Treatment of Nonuremic Calciphylaxis: A Complication of Prolonged Steroid Use in Lupus Nephritis.

Nonuremic calciphylaxis (NUC) is a rare and debilitating form of panniculitis. NUC is associated with a high mortality rate within the first year of diagnosis. Connective tissue diseases account for a small fraction of the reported cases. However, there have also been reported cases of patients developing NUC while on treatment with chronic corticosteroid immunosuppressive therapy. The pathophysiology of NUC is still not fully established. Several risk factors including underlying diseases, obesity, female gender, and medications have been associated with the development of NUC. The diagnosis remains challenging due to the condition's similarities with other forms of panniculitis. The gold standard for diagnosis is a tissue biopsy showing calcifications within the medial layer of arterioles and the presence of microthrombi with surrounding necrosis. The treatment for NUC has not advanced much in recent years and focuses on the management of the underlying condition, wound care, and treating any superimposed infection. Treating superimposed infections remains important as most of the associated mortality from NUC occurs due to sepsis. We describe a case of a young woman with lupus nephritis who developed NUC while on prolonged corticosteroid therapy. She did not respond to several immunosuppressive agents and was ultimately treated with rituximab, a monoclonal antibody against CD20 antigen, as salvage therapy.

Diabetes Mellitus Increases the Risk of Significant Hepatic Fibrosis in Patients With Non-alcoholic Fatty Liver Disease.

Background: Diabetes mellitus is associated with an increased risk of development of non-alcoholic fatty liver disease (NAFLD). However, the risk posed by diabetes mellitus in progression of liver disease is uncertain. This study compared the severity of hepatic fibrosis in patients with NAFLD with and without diabetes mellitus. Methods: Consecutive adult patients with NAFLD undergoing transient elastography [FibroScan Touch 502 (Echosens, Paris, France)] at a tertiary care center in north India were analyzed for severity of hepatic fibrosis. The aspartate aminotransferase (AST) to platelet ratio index (APRI), fibrosis index based on 4 factors (FIB-4), and NAFLD Fibrosis Score (NFS) were calculated. The degree of hepatic fibrosis as determined by FibroScan and non-invasive serum fibrosis models in patients with and without diabetes mellitus were compared. Results: A total of two hundred patients [118 (59%) males, mean age 50.30 ± 11.13 years] were enrolled. Significant hepatic fibrosis was present in 86 (43%) patients [mean age 50.66 ± 10.96 years, 56 (65.11%) males]. The mean FibroScan, APRI, FIB-4, and NFS scores were 9.86 ± 2.97, 0.75 ± 0.47, 2.41 ± 1.41 and -0.24 ± 1.43 in patients with diabetes compared to 5.31 ± 1.09, 0.49 ± 0.27, 1.55 ± 0.85, and -2.12 ± 1.88 in patients without diabetes, respectively (P=<0.0001). There was a fair correlation between FibroScan and non-invasive serum fibrosis models (P=<0.0001). Conclusion: Presence of diabetes increases the risk of significant hepatic fibrosis in patients with NAFLD. FIB-4 correlates fairly with FibroScan in patients with diabetes and can be used as a screening tool to detect significant hepatic fibrosis.

Bifascicular block in unexplained syncope is underrecognized and under-evaluated: A single-center audit of ESC guidelines adherence.

BACKGROUND: The presence of bifascicular block on electrocardiography suggests that otherwise-unexplained syncope may be due to complete heart block. European Society of Cardiology (ESC) recommends investigating it with electrophysiology study (EPS). PPM is indicated if high-degree atrioventricular block is inducible. Long term rhythm monitoring with implantable loop recorder (ILR) is recommended if EPS is negative. We evaluated adherence to these guidelines. METHODS: This is a single-center retrospective audit of adult patients with bifascicular block hospitalized for unexplained syncope between January 2018 and August 2019 under general medicine service. Patients with an alternative explanation for syncope were excluded. Guideline adherence was assessed by formal cardiology consult and whether EPS followed by ILR and/or PPM were offered. RESULTS: 65 out of 580 adult patients (11.2%) admitted to general medicine service for syncope had a bifascicular block; 29 (5%) were identified to have bifascicular block and unexplained syncope. Median age was 77 ±10 years; 9 (31%) were female, and 6 (20.7%) patients had at least one prior hospital visit for syncope at our academic medical center. Cardiology was consulted on 17 (58.6%) patients. Two patients were evaluated by EPS (1 refused) followed by ILR. Overall, 3 out of 29 patients (10.3%) received guideline-directed evaluation during the hospitalization based on ESC guidelines. None of the patients received empiric PPM during the index hospitalization. CONCLUSION: Among patients admitted to the general medicine service with unexplained syncope and bifascicular block, a minority (10.3%) underwent guideline-directed evaluation per ESC recommendations. Cardiology was consulted in 58.6% of cases.

Utilization of Rituximab for Refractory Rowell Syndrome.

Rowell syndrome describes the occurrence of erythema multiforme-like lesions in patients with cutaneous lesions of lupus erythematosus. The clinical picture of atypical erythema multiforme-like lesions, presence of chilblains, speckled ANA pattern, anti-Ro/SSA, or anti-La/SSB antibodies, and absence of infectious or pharmacologic triggers in a patient with systemic lupus erythematosus are some of the classic clinical and serologic features. Histopathologic and serologic findings can help differentiate this process from erythema multiforme. We present a case of young woman with systemic lupus erythematosus, end-stage renal disease due to lupus nephritis, and a remote history of Steven-Johnson syndrome due to sulfa allergy who presented to the hospital with a recurrent, progressive, targetoid erythematous rash involving more than 60% of her body surface area. Our patient had several hospitalizations in the recent past for this erythematous rash and had failed oral therapy with prednisone 1 mg/kg and hydroxychloroquine. In view of the minimal improvement and increasing severity and patient exhibiting early features of mast cell activation syndrome, the patient was treated with pulse intravenous glucocorticoids followed by rituximab with an excellent response. We highlight a unique case report of progressive Rowell syndrome refractory to standard of care with an excellent response to rituximab.

Does withdrawal of immunosuppression in rheumatoid arthritis after SARS-CoV-2 infection increase the risk of vasculitis?

We describe a case of a 48-year-old woman who presented with acute respiratory failure due to diffuse alveolar haemorrhage and acute renal failure due to pauci-immune glomerulonephritis consistent with a new diagnosis of microscopic polyangiitis (MPA). The patient had a recent SARS-CoV-2 infection 6 weeks before MPA diagnosis and had stopped immunosuppression for her rheumatoid arthritis (RA) at that time. The patient was treated with pulse intravenous steroids, plasma exchange therapy and rituximab, which induced remission of her illness. This case highlights a timely dilemma of holding immunosuppression in a RA patient with low disease activity on combination therapy with SARS-CoV-2 infection, and the potential risk of developing an additional autoimmune disease, such as vasculitis, given their existing autoimmunity due to RA.

Patient Perception of Cardiovascular Risk in Rheumatoid Arthritis.

OBJECTIVE: Patients with rheumatoid arthritis (RA) have higher incidence of cardiovascular diseases (CVDs) compared with age- and sex-matched controls. The objective of our study was to measure the knowledge of patients with RA about the association between their disease and cardiovascular (CV) risk and to measure the frequency of counseling by physicians based on patient report. METHODS: A telephone survey was conducted among patients with RA enrolled in the Consortium of Rheumatology Researchers of North America RA registry to collect data on medical and social history and on knowledge about CVD risk in RA and how they learned about that risk. Multivariable logistic regression models were performed to determine the factors associated with patients' knowledge and factors influencing likelihood of physician counseling. The odds ratios (ORs) represent adjusted multivariable results. RESULTS: Of 185 patients with RA included in the study, 87 patients (47%) were aware that RA was a CV risk factor. Older age (OR 0.6; 95% confidence interval [CI] 0.4-0.8 per decade) and smoking (OR 0.4; 95% CI 0.1-0.9) were associated with low awareness, whereas disease duration of more than 10 years (OR 5.2; 95% CI 2.2-12.1) was positively associated with patient knowledge. Counseling by physicians, mostly rheumatologists, on CV risk in RA was reported by 47 patients (25%). Disease duration of more than 10 years (OR 3.9; 95% CI 1.2-13.1) was positively associated with patient-reported counseling. Patients with hypertension were less likely to report counseling (OR 0.4; 95% CI 0.2-0.9). CONCLUSION: Our study demonstrated low patient awareness of CV risk with RA and low rates of patient-reported counseling by physicians. This is an unmet need in clinical practice, which may be overcome by multimodal approaches such as developing websites, organizing symposiums, and involving health care providers at various levels.

Efficacy of anakinra for idiopathic and non-idiopathic pericarditis refractory or intolerant to conventional therapy.

BACKGROUND: Anakinra, a recombinant interleukin-1 receptor antagonist is effective in treatment of idiopathic recurrent pericarditis. However, its efficacy in non-idiopathic pericarditis (secondary to a diagnosed inflammatory condition, or other known etiology) is unclear. We evaluated the efficacy of anakinra in patients with non-idiopathic (secondary to a diagnosed inflammatory condition, or other known etiology) and idiopathic pericarditis, who were intolerant or refractory to conventional therapy (colchicine and corticosteroids). METHODS: This was a single-center study in which we performed a retrospective chart review of consecutive adult patients hospitalized with pericarditis intolerant or refractory to conventional therapy who were treated with conventional therapy and anakinra between January 2016-October 2018. The control group included age-matched hospitalized pericarditis patients treated with conventional therapy only. Symptom relief at discharge, time to symptom relief and recurrence on treatment were compared. The effect of outpatient continuation of anakinra on post-treatment recurrence risk was assessed. RESULTS: Twelve patients received anakinra for pericarditis; 22 age-matched controls were identified. Ten patients (83.3%) in the conventional therapy and anakinra group and 13 patients (54.1%) in the conventional therapy groups had non-idiopathic pericarditis. All conventional therapy and anakinra patients and 16 of 22 patients in the conventional therapy group reported symptom relief at discharge (p=0.04). Time to symptom relief was decreased in the conventional therapy and anakinra group (3.75±1.87 vs 5.63±3.28 days, p=0.08). During treatment, all conventional therapy and anakinra-treated patients continued to be symptom free, while nine of 22 conventional therapy patients (40.9%) experienced recurrence (p=0.009). Recurrence risk after treatment discontinuation was similar in the conventional therapy and anakinra group and the conventional therapy group. CONCLUSIONS: In hospitalized patients with non-idiopathic or idiopathic pericarditis refractory, or intolerant to, conventional therapy, anakinra is associated with improved symptom relief and decreased recurrence risk during treatment.

An Unusual Presentation of Granulomatosis with Polyangiitis (GPA).

BACKGROUND This is a very interesting case of Granulomatosis with Polyangiitis (GPA) presenting with hand ischemia which rapidly evolved into dry gangrene from the involvement of digital arteries. GPA usually affects the small and medium sized blood vessels. GPA affecting muscular artery causing limb ischemia is a rare manifestation. CASE REPORT A 72 years old Caucasian female was sent to our hospital for the evaluation of left hand pain and bluish discoloration, which she noticed for few days. Physical examination was notable for bluish discoloration of left 2nd to 5th fingers, which later evolved, into dry gangrene at the tips. Angiogram revealed ischemia with no evidence of thrombosis. Administration of intra-arterial nitroglycerin resulted in improved blood flow through the radial artery. Labs revealed ESR of 142 mm/hr. C-ANCA titer was 5120, (normal <20) and antiproteinase 3 was 1117 (normal <20) consistent with GPA. CONCLUSIONS GPA usually affects the small and medium sized blood vessels. This case highlights an unusual presentation of GPA manifesting as critical limb ischemia. Given the rarity of this circumstance, a high index of suspicion is necessary in order to initiate proper treatment and limb salvaging intervention.

Total hip replacement as primary treatment of unstable intertrochanteric fractures in elderly patients.

Fifty-three patients with A2.2 and A2.3 intertrochanteric fracture according to the Muller classification were treated with total hip replacement between April 2000 and February 2004. The average age of the patients was 77 years. Average follow-up period was 3.7 years. We studied postoperative complications, mortality rate, functional outcome using the Harris hip score, time to return to normal activities, and radiographic evidence of healing. Two patients died on the third and fifth postoperative days. Seven more patients died within one year. The Harris hip score at one month was 66 +/- 7 (mean +/- standard deviation); at three months 72 +/- 6; at one year 74 +/- 5; at three years 76 +/- 6 and in the 27 patients who completed five year follow-up it was 76 +/- 8. Mobilisation and weight-bearing was started immediately in the postoperative period. Average time taken to return to normal daily activities was 28 days (range 24-33). No loosening or infection of the implants was observed. Total hip arthroplasty is a valid treatment option for mobile and mentally healthy elderly patients with intertrochanteric fractures. This procedure offers quick recovery with little risk of mechanical failure, avoids the risks associated with internal fixation and enables the patient to maintain a good level of function immediately after surgery.