Clinical significance of cerebrospinal fluid presepsin as adjunctive biomarker for postneurosurgical meningitis: A single-center prospective observational study.

Background: Postneurosurgical meningitis (PNM) is a serious complication in neurocritical care patients, leading to clinical deterioration and worsening outcomes. Accurate diagnosis of PNM is often difficult due to the lack of definitive diagnostic criteria. This study investigates the potential utility of cerebrospinal fluid (CSF) presepsin (PSP), blood PSP, and the CSF/blood PSP ratio as adjunctive biomarkers for the diagnosis of PNM. Methods: We conducted a single-center prospective observational study at Nara Prefecture General Medical Center in Nara, Japan, from April 2020 to March 2022. The postoperative neurosurgical patients with suspected PNM were included in the study and divided into PNM and non-PNM groups. We evaluated the sensitivity, specificity, area under curves (AUCs), positive predictive value (PPV), and negative predictive value (NPV) for the diagnosis of PNM with CSF PSP, blood PSP, and CSF/blood PSP ratio compared in the two groups. Results: We screened 241 consecutive patients with postoperative neurosurgery. Diagnosis of PNM was suspected in 27 patients, and the clinical diagnosis was confirmed in nine patients. The results of CSF PSP (cutoff: 736 pg/mL) for the diagnosis of PNM were sensitivity 89%, specificity 78%, PPV 67%, NPV 93%, AUC 0.81 (95% confidence interval [CI], 0.60-1.00), blood PSP (cut-off: 264 pg/mL) was 56%, 78%, 56%, and 78%, 0.65 (95% CI, 0.42-0.88), and those of CSF/blood PSP ratio (cutoff: 3.45) was 89%, 67%, 57%, and 92%, 0.83 (95% CI, 0.65-1.00). Conclusion: Elevated CSF PSP and CSF/blood PSP ratio may be associated with PNM and could serve as valuable adjunctive biomarkers for improving diagnostic accuracy.

Von Willebrand Factor Antigen Levels Predict Poor Outcomes in Patients With Stroke and Cancer: Findings From the Multicenter, Prospective, Observational SCAN Study.

BACKGROUND: Patients with acute ischemic stroke and active cancer have more severe neurological symptoms, elevated risks of stroke recurrence, and death compared with the general population. We examined whether von Willebrand factor (vWF) antigen levels at stroke onset were associated with the poor outcomes of patients with stroke and cancer. METHODS AND RESULTS: Using data from 90 patients with acute ischemic stroke and active cancer who were registered in the SCAN (Ischemic Stroke in Patients With Cancer and Neoplasia) study, a prospective multicenter, observational study in Japan, we divided patients into 2 groups according to their median vWF antigen levels (high, n=46; or low, n=44). The high-vWF group had a significantly higher initial National Institutes of Health Stroke Scale score (median, 7 [interquartile range, 3-11.25] versus 3 [interquartile range, 1-8.5]; P<0.05) and a significantly higher incidence of cryptogenic stroke (32 [70%] versus 16 [36%]; P<0.01) and venous thromboembolism (7 [15%] versus 0 [0%]; P<0.01), as well as multiple lesions (28 [62%] versus 12 [27%]; P<0.001), than the low-vWF group. We observed no significant difference in the rate of stroke recurrence within 1 year between the groups. However, increased vWF levels were an independent predictor of death within 1 year of stroke onset, after adjusting for potential confounders (odds ratio, 6.77 [95% CI, 1.49-30.78]; P<0.05). CONCLUSIONS: Elevated vWF antigen levels were associated with adverse outcomes in patients with cancer-associated stroke and may represent a useful biomarker to guide future therapeutic interventions.

Association of Antipsychotic Drugs with the Risk of Recurrent Venous Thromboembolism: A Retrospective Study of Data from a Japanese Inpatient Database.

BACKGROUND: Approximately a decade has passed since the addition of venous thromboembolism to the list of significant adverse reactions of antipsychotic drugs. However, only a few studies have investigated the relationship between antipsychotic use and venous thromboembolism in the Japanese population. PURPOSE: We aimed to evaluate the risk of recurrent venous thromboembolism in users of antipsychotic drugs and update the evidence on venous thromboembolism in the Japanese population. METHODS: A cross-sectional retrospective analysis of data from a large Japanese claims database, managed by Medical Data Vision Co. Ltd., was conducted. Adult patients who experienced venous thromboembolism between October 2014 and September 2018 in acute care hospitals were identified. The risk of recurrent venous thromboembolism was evaluated with logistic regression using demographic variables. The data of patients using antipsychotic drugs within specific therapeutic classes were also evaluated. RESULTS: We included 8960 patients (mean age, 69 years; 59.2% female). Recurrent venous thromboembolism was observed in 686 patients (7.7%). The risk of recurrent venous thromboembolism was significantly higher in younger patients [< 65 years: reference; 65-74 years: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.66-0.99, p = 0.04; ≥ 75 years: OR 0.77, 95% CI 0.64-0.94, p = 0.01], those with history of surgery (OR 1.39, 95% CI 1.18-1.65, p = 0.01), and anticoagulant users (OR 2.25, 95% CI 1.46-3.48, p = 0.01) and was significantly lower in the presence of comorbidities (OR 0.68, 95% CI 0.58-0.81, p< 0.01) and fractures (OR 0.49, 95% CI 0.26-0.94, p = 0.03). Long-term antipsychotic drug prescriptions (> 14 days) were associated with a higher risk of venous thromboembolism than short-term prescriptions (≤ 14 days) (OR 1.56, 95% CI 1.04-2.34, p = 0.03). CONCLUSIONS: In patients with a history of venous thromboembolism, particular attention should be paid to recurrence in younger patients. If antipsychotic drugs are prescribed for > 14 days to patients with a history of venous thromboembolism, they should be administered carefully, guided by reported findings. Further evaluations using different databases or populations are required to generalize the findings of this study.

Pharmacological profile of upacicalcet, a novel positive allosteric modulator of calcium-sensing receptor, in vitro and in vivo.

Upacicalcet (formerly SK-1403/AJT240) is a novel non-peptide calcimimetic agent that acts as a calcium-sensing receptor (CaSR) agonist for the treatment of secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD). We compared upacicalcet with other calcimimetics (etelcalcetide or cinacalcet) and examined its in vitro and in vivo characteristics in terms of its human CaSR agonistic activity, its efficacy in normal and CKD rats after a single administration, and its effect on gastric emptying in rats. Upacicalcet activated human CaSR depending on the extracellular calcium (Ca2+) concentration without exhibiting an agonistic action when the extracellular Ca2+ level was below the physiological level. On the other hand, etelcalcetide had an agonistic activity even in the absence of physiological levels of extracellular Ca2+. The intravenous administration of upacicalcet to normal and double-nephrectomized rats dose-dependently (0.03-3mg/kg and 0.3-30mg/kg, respectively) decreased the serum intact parathyroid hormone (iPTH) and serum Ca2+ levels; however, the effect of upacicalcet on the reduction in serum Ca2+ disappeared at extracellular Ca2+ levels below the physiologically range, even when administered at a dose higher (100-fold) than the effective dose. Furthermore, upacicalcet did not affect gastric emptying in normal rats when administered up to a dose of 10mg/kg (300-fold higher than the dose affecting serum iPTH levels), while the administration of cinacalcet significantly slowed gastric emptying by approximately 50%. These findings suggest that upacicalcet has potential as an alternative calcimimetic agent with good pharmacological properties and a lower risk of hypocalcemia and gastrointestinal complications.

Predictors of Survival in Patients With Ischemic Stroke and Active Cancer: A Prospective, Multicenter, Observational Study.

Background Limited data exist on the prognostic factors for patients with ischemic stroke and active cancer. Methods and Results We conducted a prospective, multicenter, observational study in Japan, including patients with acute ischemic stroke and active cancer, to investigate the prognostic factors. We followed up the patients for 1 year after stroke onset. The patients were divided into 2 groups according to cryptogenic stroke and known causes (small-vessel occlusion, large-artery atherosclerosis, cardioembolism, and other determined cause), and survival was compared. The hazard ratios (HRs) and 95% CIs for mortality were calculated using Cox regression models. We identified 135 eligible patients (39% women; median age, 75 years). Of these patients, 51% had distant metastasis. A total of 65 (48%) and 70 (52%) patients had cryptogenic stroke and known causes, respectively. Patients with cryptogenic stroke had significantly shorter survival than those with known causes (HR [95% CI], 3.11 [1.82-5.32]). The multivariable Cox regression analysis revealed that distant metastasis, plasma D-dimer levels, venous thromboembolism (either deep venous thrombosis or pulmonary embolism) complications at stroke onset were independent predictors of mortality after adjusting for potential confounders. Cryptogenic stroke was associated with prognosis in univariable analysis but was not significant in multivariable analysis. The plasma D-dimer levels stratified the prognosis of patients with ischemic stroke and active cancer. Conclusions The prognosis of patients with acute ischemic stroke and active cancer varied considerably depending on stroke mechanism, distant metastasis, and coagulation abnormalities. The present study confirmed that coagulation abnormalities were crucial in determining the prognosis of such patients.

Association between urate-lowering therapy and cardiovascular events in patients with asymptomatic hyperuricemia.

INTRODUCTION/OBJECTIVES: To investigate the role of urate-lowering therapy (ULT) in the prevention of cardiovascular disease (CVD) in patients with asymptomatic hyperuricemia using the Japanese healthcare record database. METHODS: This retrospective cohort study used data from the JMDC Claims Database, which includes records of medical check-ups and Japanese health insurance claims. Subjects aged at least 18 years with a serum uric acid (sUA) level ≥ 7.0 mg/dL and at least one medical check-up from January 2007 to August 2021 were included in this study. The exposure was any ULT prescription, and the primary outcome included composite CVD outcomes, including coronary artery disease, stroke, and atrial fibrillation. Analysis was performed with a new-user design and overlap weighting to balance the baseline characteristics of the subjects. Cox proportional hazards models were used to investigate the association between ULT and the development of CVD. RESULTS: In total, 152,166 patients were included in the main analysis before overlap weighting in this retrospective cohort study. The number of subjects in the ULT group was 5,270, and there were 146,896 subjects in the control group. Composite CVD outcomes were observed in a total of 7,703 patients. The risk of developing composite CVD outcomes was not different between the ULT group and the control group (HR: 1.01, 95% CI: 0.89 to 1.13). CONCLUSIONS: ULT for patients with asymptomatic hyperuricemia did not prevent the development of CVD based on the Japanese claims database. Key points • Among subjects with asymptomatic hyperuricemia, ULT was not associated with a lower risk of CVD • There was no appropriate cutoff for initiating ULT in patients with asymptomatic hyperuricemia • There was no appropriate cutoff as the therapeutic goal of ULT in patients with asymptomatic hyperuricemia.

Association between dose reduction of renin-angiotensin-aldosterone system inhibitors before coronary artery angiography and acute kidney injury: a propensity score-matched study.

OBJECTIVE: The aim of this study was to investigate the association between dose reduction of renin-angiotensin-aldosterone system inhibitors (RAASis) and Acute kidney injury (AKI). AKI, which is commonly observed in hospitalized patients, increases mortality. Although RAASis and coronary artery angiography (CAG) are reported to be risk factors for AKI, whether dose reduction of RAASis can prevent AKI after CAG remains unknown. METHODS: In this retrospective propensity score (PS)-matched cohort from the RWD database, which includes 20 million patients from 190 hospitals in Japan, we examined the impact of dose reduction of RAASis on the development of AKI after CAG. The subjects were patients with an estimated glomerular filtration rate (eGFR) of 15-60 mL/min/1.73 m2, and the exposure of interest was the presence of a dose reduction in RAASis within 3 days before CAG was performed. Propensity score matching was performed with 19 baseline characteristics using a logistic regression model. RESULTS: We identified 3329 patients who were prescribed RAASis at least one month before admission and underwent CAG. Six hundred seventy-four patients had a dose reduction 3 days prior to undergoing CAG, and 2655 patients did not. AKI was observed in 34 (5.0%) patients in the reduction group and 137 (5.2%) patients in the control group. There was no significant difference in the primary outcome between the two groups in the PS-matched cohort (OR: 1.08, 95% CI: 0.70-1.66). CONCLUSIONS: A reduction in the dose of RAASis did not prevent the development of AKI among patients undergoing CAG.

Predictive value of computed tomography for short-term mortality in patients with acute respiratory distress syndrome: a systematic review.

The best available evidence and the predictive value of computed tomography (CT) findings for prognosis in patients with acute respiratory distress syndrome (ARDS) are unknown. We systematically searched three electronic databases (MEDLINE, CENTRAL, and ClinicalTrials.gov). A total of 410 patients from six observational studies were included in this systematic review. Of these, 143 patients (34.9%) died due to ARDS in short-term. As for CT grade, the CTs used ranged from 4- to 320-row. The index test included diffuse attenuations in one study, affected lung in one study, well-aerated lung region/predicted total lung capacity in one study, CT score in one study and high-resolution CT score in two studies. Considering the CT findings, pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 62% (95% confidence interval [CI] 30-88%), 76% (95% CI 57-89%), 2.58 (95% CI 2.05-2.73), 0.50 (95% CI 0.21-0.79), and 5.16 (95% CI 2.59-3.46), respectively. This systematic review revealed that there were major differences in the definitions of CT findings, and that the integration of CT findings might not be adequate for predicting short-term mortality in ARDS. Standardisation of CT findings and accumulation of further studies by CT with unified standards are warranted.

[Secondary Contamination by Wheat Allergens across Cooking Bowls through the Use of Sponge Scourers].

After washing the cooking utensils used to prepare liquid batter, flour may remain in the scrubbing sponge. Secondary contamination of cooking devices with wheat allergens is a concern if such scrubbing sponges are used to clean other equipment. Therefore, in this study, bowl washing with detergent, using a scrubbing sponge was evaluated as a cleaning method following liquid batter cooking. Multiple trials revealed that wheat allergens were transferred from a bowl coated with 10 g of liquid batter to an unused bowl via sponge scrubbing with a positive rate of approximately 80%. Residual batter was observed in the scrubbing sponge after cleaning and rinsing procedures, with a residual rate of about 20%. Detailed observation of the residue revealed that proteins such as gluten were attached to the cell skeleton, and between the skeletons of the sponge, and starch granules were attached to the proteins. Even with sponge rinsing conditions added to the protocol, complete removal of wheat allergen was difficult. These studies indicate that particular scrubbing sponges for cleaning the residual wheat on cooking utensils should be dedicated exclusively in cooking facilities that prepare allergy-friendly-foods to avoid risk of allergen contamination.

Mixed Reality Needle Guidance Application on Smartglasses Without Pre-procedural CT Image Import with Manually Matching Coordinate Systems.

PURPOSE: To develop and assess the accuracy of a mixed reality (MR) needle guidance application on smartglasses. MATERIALS AND METHODS: An MR needle guidance application on HoloLens2, without pre-procedural CT image reconstruction or import by manually matching the spatial and MR coordinate systems, was developed. First, the accuracy of the target locations in the image overlay at 63 points arranged on a 45 × 35 × 21 cm box and needle angles from 0° to 80°, placed using the MR application, was verified. The needle placement errors from 12 different entry points in a phantom by seven operators (four physicians and three non-physicians) were compared using a linear mixed model between the MR guidance and conventional methods using protractors. RESULTS: The average errors of the target locations and needle angles placed using the MR application were 5.9 ± 2.6 mm and 2.3 ± 1.7°, respectively. The average needle insertion error using the MR guidance was slightly smaller compared to that using the conventional method (8.4 ± 4.0 mm vs. 9.6 ± 5.1 mm, p = 0.091), particularly in the out-of-plane approach (9.6 ± 3.5 mm vs. 12.3 ± 4.6 mm, p = 0.003). The procedural time was longer with MR guidance than with the conventional method (412 ± 134 s vs. 219 ± 66 s, p < 0.001). CONCLUSION: MR needle guidance without pre-procedural CT image import is feasible when matching coordinate systems, and the accuracy of needle insertion is slightly better than that of the conventional method.

Association between biopsies for anti-neutrophil cytoplasmic antibody-associated vasculitis and prognosis: a retrospective cohort study.

OBJECTIVES: Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a systemic vasculitis with unknown aetiology. Although biopsies are helpful for diagnosing AAV, whether they improve the outcomes of AAV patients remains unknown. The objective of this study was to elucidate the association between biopsies and prognosis. METHOD: This retrospective cohort study analysed health care records that were routinely collected at 190 hospitals in Japan from April 2005 to March 2019. Patients who were 18 years or older and hospitalized for AAV were eligible for inclusion. The primary outcome was the composite outcome of death and renal replacement therapy (RRT) during the first admission. We compared the outcome between the biopsy group and the no-biopsy group. The chi-square test was performed as a univariable analysis, and logistic regression analysis was performed as a multivariable analysis. RESULTS: Three hundred and eighty-six patients were assessed in this study. One hundred fifty-four (39.9%) patients underwent biopsy, and 232 (60.1%) patients did not undergo biopsy during the first admission with AAV. In univariable analysis, the composite outcome of death and RRT were observed in 7 (4.5%) patients in the biopsy group and 25 (10.8%) patients in the no-biopsy group (OR 0.39 [95% CI 0.17, 0.94], P = 0.01). The result was consistent in the multivariable analysis (OR 0.31 [95% CI 0.12, 0.79], P = 0.01) after adjusting for potential confounders. CONCLUSIONS: We showed that patients who underwent biopsy had a better prognosis in the composite outcome of mortality and RRT during admission using a Japanese healthcare record database. Key Points • This is the first study to elucidate the association between undergoing biopsy and prognosis. • Patients undergoing biopsy had a better prognosis in the composite outcome of mortality and RRT. • The proportion of patients who received transfusions was not significantly different between the two groups.

Clinical Utility of Surgical Lung Biopsy for Patients with Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis.

BACKGROUND: Surgical lung biopsy (SLB) is performed in patients with acute respiratory distress syndrome (ARDS); however, its clinical utility remains unclear. OBJECTIVES: We categorized the pathological diagnoses and investigated the predictive value for short-term mortality. METHOD: Three electronic databases (MEDLINE, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov) were searched for the included studies. The QUADAS-2 was used to evaluate the risk of bias and its applicability. The types and populations of pathological diagnoses were investigated. The pooled sensitivity, positive likelihood ratio (LR+), negative likelihood ratio (LR-), and diagnostic odds ratio (DOR) were estimated at a fixed specificity. Hierarchical summary receiver operating characteristic curves were drawn. RESULTS: A total of 16 studies that enrolled 758 patients were included. The pathological diagnoses were as follows: diffuse alveolar damage (DAD) 29.9%; infection 24.7%; interstitial lung disease 17.2%; malignancy 3.6%; cardiovascular disease 3.6%; drug toxicity 2.3%; connective tissue disease 2.2%; allergic disease 1.1%; and nonspecific diagnosis 15.4%. To predict short-term mortality, 13 studies that enrolled 613 patients used DAD as an index test and recorded a mortality rate of 56.9% (349 of 613 patients). A total of 3 studies that used index tests other than DAD were excluded. The pooled sensitivity, fixed specificity, LR+, LR-, and DOR were 0.46 (95% confidence interval [CI]: 0.29-0.56), 0.69, 1.48 (95% CI: 0.92-1.81), 0.78 (95% CI: 0.63-1.03), and 1.90 (95% CI: 0.89-2.86), respectively. CONCLUSIONS: SLB is unlikely to provide a specific diagnosis and should not be recommended for confirming DAD or predicting ARDS prognosis.

Scald Burns While Bathing Among Elderly People in Japan.

Night baths are an essential and beloved tradition in Japanese households. The main purpose of taking a bath at the end of the day, besides hygiene, is relaxation. The aging population is rapidly growing in Japan, as one in three people are approaching the age of 65 years or older. Furthermore, with the progress of nuclear families, the number of households with only elderly people and the need for elderly care is increasing. In recent years, elderly people experienced burns caused by hot water during bathing. We report two cases of water bath burns experienced by elderly people. The first is a case of a 68-year-old woman who presented with a history of type 2 diabetes and osteoarthritis in both knees. She did not notice that the bath stopper was unplugged while she was taking a bath, and she added hot water at around 44°C. She was exposed to hot fluid on the right foot and suffered deep dermal burns. However, due to knee osteoarthritis, it became difficult for her to move. Two hours after taking a bath, she was removed from the bathtub. The second is a case of a 71-year-old woman who presented with a history of type 2 diabetes and osteoarthritis in both knees. Because the temperature of the bath was approximately 44°C, she tried to cool down the water, but it was difficult for her to move because of knee osteoarthritis. She called out for help from her family living in the neighborhood, but she could not get out. She was sitting for about 2 hours before being noticed by her family. As a result, she suffered second-degree burns on both the buttocks and soles of her feet. Prolonged exposure to thermal liquids and burns such as low-temperature burns are caused by individual factors, such as decreased perception, orthopedic disease, and difficulty in moving due to fainting, and social factors such as delay in discovery in elderly people living alone. These factors lead to an increased depth of the burn.

Injectable Biocatalytic Nanocomposite Hydrogel Factories for Focal Enzyme-Prodrug Cancer Therapy.

Systemic enzyme-prodrug therapy (EPT) using nanofactories, nanoparticles encapsulating prodrug-activating enzymes, is a promising concept for anticancer therapy. However, systemic delivery systems can be problematic. As nanofactories are typically carried by the blood circulation to tissues throughout the body, conversion of anticancer drugs in normal tissues can cause severe side effects. To overcome this problem, we developed a novel focal EPT approach utilizing nanocomposite hydrogels composed of a poly(dl-lactide-co-glycolide)-b-poly(ethylene glycol)-b-poly(dl-lactide-co-glycolide) (PLGA-PEG-PLGA) copolymer, LAPONITE, and ß-galactosidase (ß-gal). The nanocomposite gels can be easily injected locally, and the inherent enzyme activity of ß-gal can be preserved long-term. Prodrug 5-FU-ß-gal readily permeated into the interior space of gels and was converted into the active anticancer drug 5-FU. Importantly, a single local injection of nanocomposite gels and prodrug 5-FU-ß-gal provided long-lasting antitumor activity in vivo without observable side effects, demonstrating the potential utility of injectable biocatalytic hydrogel factories for novel focal EPT systems.

Radiation dose for 320-row dose-modulated dynamic coronary CT angiography.

OBJECTIVES: The area detector 320-row CT scanner, which can cover the whole heart in one rotation, can aid in reducing radiation exposure during electrocardiography (ECG)-gated coronary CT angiography (CCTA). Recently, researchers have proposed dose-modulated dynamic CCTA with a 320-row scanner for the detection of functional myocardial ischemia. In the present study, we compared and validated the radiation dose of this method with that of the standard CCTA method and the latest diagnostic reference levels (DRLs). MATERIALS AND METHODS: The study included a total of 164 consecutive patients with suspected or known coronary artery disease (CAD) who underwent CCTA with a 320-row scanner. The patients were randomly divided into dynamic and standard CCTA groups, and the CT dose index (CTDIvol) and dose length product (DLP) calculated by the CT system were compared between the two protocols and with the latest DRL. RESULTS: Standard and dynamic CCTA scans were performed in 77 and 87 patients, respectively. CTDIvol was significantly higher for standard CCTA than for dynamic CCTA (41 ± 35 mGy vs. 22 ± 7 mGy, p = 0.0014). DLP was also significantly higher for standard CCTA than for dynamic CCTA (864 ± 702 mGy × cm vs. 434 ± 106 mGy × cm, p < .0001). For standard scans, CTDIvol and DLP exceeded the 2020 DRL in Japan in 16% (12/77) and 17% (13/77) of cases, respectively. In contrast, rates for the dynamic scan were only 1% (1/87) for CTDIvol and 0% (0/87) for DLP. CONCLUSION: The dose of radiation exposure during dynamic CCTA with a 320-row scanner does not exceed that of standard CCTA and is sufficient to meet the latest DRL. Thus, our results suggest that the method is safe from the perspective of radiation exposure.

Duplicated Middle Cerebral Artery Aneurysms Treated by Coil Embolization; A Report of Two Cases and Literature Review.

BACKGROUND: Duplication of the middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery (ICA). Aneurysms at the origin of a DMCA have been reported; however, most have been treated with clipping surgery. Here, we describe two cases of aneurysms at the origin of a DMCA treated with coil embolization. CASE PRESENTATION: Case 1: A seventy-three year-old man presented with severe headache and was diagnosed with subarachnoid hemorrhage (SAH). Digital subtraction angiography (DSA) and 3-dimensional (3-D) DSA showed an aneurysm arising from a DMCA. Coil embolization was performed with DMCA patency. The patient had an uneventful postoperative course. CASE 1: A 44-year-old woman presented with a history of clipping for an IC-anterior choroidal artery (AchA) aneurysm 8 years prior. Magnetic resonance imaging (MRI) showed regrowth of the aneurysm. 3-D DSA showed an IC-DMCA aneurysm located laterally and distal to the AchA. The DMCA arose from the bottom of the aneurysm. Coil embolization was performed without DMCA occlusion and showed no postoperative ischemic changes. CONCLUSION: An IC-DMCA aneurysm is rare and may be misdiagnosed as an AchA aneurysm. Clinicians should perform a 3D-DSA evaluation if the aneurysm arises from the lateral wall of the IC to obtain a precise diagnosis and to preserve the DMCA during coil embolization.

A clinical and statistical analysis of abscess in cellulitis.

The features of abscess that forms in cellulitis patients were investigated. Among 449 cellulitis cases, about 15% developed abscess, and about 70% of teenaged patients were abscess cases. Furthermore, abscess in the younger age group occurred almost exclusively among male patients. The lesion was predominantly concentric at all ages in the abscess group and in teenagers in the non-abscess group. In contrast, it was diffuse in patients ≥20 years old in the non-abscess group. The clinical symptoms and laboratory values in the abscess group were generally more severe than those in the non-abscess group, especially in the older age group. The abscess sizes increased with the initial area of the lesions. Most abscess cases received incision, and post-incision ulcers were mostly conservatively treated. The duration required for treatment termination was >30 days longer in the abscess group than in the non-abscess group. When post-incision ulcers were conservatively treated, the duration until healing increased with abscess size. However, the durations did not significantly differ between the conservatively and surgically treated groups. When surgically treated, many ulcers healed within 19 days after operation and the outpatient follow-up period tended to be relatively short. Most teenaged patients were student athletes, and thus needed an early return to competition. The main cause in these patients was bruising during sports, with rugby football the most common causative sport. Ulcer closure by operation was suggested to be preferable for shortening the outpatient follow-up period, especially for student athlete patients.

Locking versus nonlocking superior plate fixations for displaced midshaft clavicle fractures: A prospective randomized trial comparing clinical and radiografic results.

BACKGROUND: It is unknown whether locking or nonlocking superior plate fixation is better for managing displaced midshaft clavicle fractures. Therefore, we aimed to compare the clinical and radiographic outcomes of locking and nonlocking superior plate fixation of displaced midshaft clavicle fractures. METHODS: A total of 102 consecutive patients with displaced midshaft clavicle fractures (2B1 and 2B2 in Robinson classification) participated in this randomized controlled trial; 12 patients were excluded. Surgeries were performed using a 3.5-mm Locking Compression Plate (LCP) between 2007 and 2015. Patients were treated either with a locking plate (group L, n = 45) or a nonlocking plate (group N, n = 45). In both groups, the plates were fixed to the proximal and distal clavicle with two and/or three screws, respectively. The main outcome measures were complication rates, time to bone union, and Constant score. RESULTS: Forty-two patients in group L (mean age, 45.9 years) and 41 in group N (mean age, 43.6 years) were followed. The overall complication rates in groups L and N were 7.2% (three peri-implant fractures) and 7.3% (non-union, deformed plate, and peri-implant fracture), respectively (p = .98). The average time to union significantly differed between groups (L vs. N: 13.0 ± 4.1 vs. 17.5 ± 6.3 weeks; p < .01). However, the Constant score at the final follow-up was not significantly different between groups (L vs. N: 87.0 ± 12.3 vs. 89.8 ± 9.1). CONCLUSIONS: Similar complication rates and clinical results were found for locking and nonlocking superior plate fixation for displaced midshaft clavicle fractures. However, the time to bone union was shorter with the locking plate. This study suggests that both plating systems are effective for treating displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Therapeutic, level I.