Rodent Inferior Vena Cava Venoplasty Balloon Model.

Balloon venoplasty is a commonly used clinical technique to treat deep vein stenosis and occlusion as a consequence of trauma, congenital anatomic abnormalities, acute deep vein thrombosis (DVT), or stenting. Chronic deep venous obstruction is histopathologically characterized by thrombosis, fibrosis, or both. Currently, no direct treatment is available to target these pathological processes. Therefore, a reliable in vivo animal model to test novel interventions is necessary. The rodent survival inferior vena cava (IVC) venoplasty balloon model (VBM) allows the study of balloon venoplasty in non-thrombotic and post-thrombotic conditions across multiple time points. The local and systemic effect of coated and uncoated venoplasty balloons can be quantified via tissue, thrombus, and blood assays such as real-time polymerase chain reaction (RT-PCR), western blot, enzyme-linked immunosorbent assay (ELISA), zymography, vein wall and thrombus cellular analysis, whole blood and plasma assays, and histological analysis. The VBM is reproducible, replicates surgical human interventions, can identify local vein wall-thrombi protein changes, and allows multiple analyses from the same sample, decreasing the number of animals required per group.

Evaluation of Efficacy of 2 Extended-release Bupivacaine Products in a Porcine Model of Incisional Pain.

Extended-release (ER) local anesthetics are often incorporated in multi-modal analgesia or as an alternative when the effect of systemic analgesics may confound research. In this study, we compared the analgesic efficacy of 2 ER bupivacaine anesthetics with different ER mechanisms, a slow-release bupivacaine-meloxicam polymer (BMP) and a sucrose acetate isobutyrate bupivacaine (SABER-B) system. We used a full-thickness unilateral skin incision porcine model to evaluate the efficacy of these 2 ER bupivacaine analgesics. Eighteen male swine were randomized into 3 groups: control (saline; n = 6), bupivacaine:meloxicam (10 mg/kg, 0.3 mg/kg; n = 6), and SABER-B (10 mg/kg; n = 6). After surgery, pigs were assessed for changes in body weight, salivary cortisol level, and response to von Frey testing at 1, 3, 6, 24, 48, 72, 96, 120, and 168 h. Body weight and salivary cortisol levels were not significantly different between groups. Based on the von Frey testing, the pigs that received analgesics showed a significantly higher withdrawal threshold of nociceptive stimulus than those that received saline at 1, 3, 6, and 24 h after the surgery. At 48 h after surgery, the SABER-B group had a significantly higher withdrawal threshold than the saline group. The withdrawal threshold was not significantly different from the baseline measurement on intact skin at 3 and 6 h after surgery in the BMP group or 1 and 3 h for the SABERB group. The analgesic effects of BMP were greatest at 3 and 6 h after surgery and that of SABER-B as 1 and 3 h SABER-B provided an earlier onset of analgesia and longer analgesia duration than did BMP. This study demonstrates that ER bupivacaine can provide pigs with 24 to 48 h of analgesia for incisional pain.

Diagnostic Imaging Utilization in the Emergency Department: Recent Trends in Volume and Radiology Work Relative Value Units.

PURPOSE: The aim of this study was to quantify and characterize the recent trend in emergency department (ED) imaging volumes and radiology work relative value units (wRVUs) at level I and level III trauma centers. METHODS: Total annual diagnostic radiology imaging volumes and wRVUs were obtained from level I and level III trauma centers from January 2014 to December 2021. Imaging volumes were analyzed by modality type, examination code, and location. Total annual patient ED encounters (EDEs), annual weighted Emergency Severity Index, and patient admissions from the ED were obtained. Data were analyzed using annual imaging volume or wRVUs per EDE, and percentage change was calculated. RESULTS: At the level I trauma center, imaging volumes per EDE increased for chest radiography (5.5%), CT (35.5%), and MRI (56.3%) and decreased for ultrasound (-5.9%) from 2014 to 2021. Imaging volumes per EDE increased for ultrasound (10.4%), CT (74.6%), and MRI (2.0%) and decreased for chest radiography (-4.4%) at the level III trauma center over the same 8-year period. Total wRVUs per EDE increased at both the level I (34.9%) and level III (76.6%) trauma centers over the study period. CONCLUSIONS: ED imaging utilization increased over the 8-year study period at both level I and level III trauma centers, with an increase in total wRVUs per EDE. There was a disproportionate increased utilization of advanced imaging, such as CT, over time. ED utilization trends suggest that there will be a continued increase in demand for advanced imaging interpretation, including at lower acuity hospitals, so radiology departments should prepare for this increased work demand.

Leaves as bottlenecks: The contribution of tree leaves to hydraulic resistance within the soil-plant-atmosphere continuum.

Within vascular plants, the partitioning of hydraulic resistance along the soil-to-leaf continuum affects transpiration and its response to environmental conditions. In trees, the fractional contribution of leaf hydraulic resistance (Rleaf ) to total soil-to-leaf hydraulic resistance (Rtotal ), or fRleaf (=Rleaf /Rtotal ), is thought to be large, but this has not been tested comprehensively. We compiled a multibiome data set of fRleaf using new and previously published measurements of pressure differences within trees in situ. Across 80 samples, fRleaf averaged 0.51 (95% confidence interval [CI] = 0.46-0.57) and it declined with tree height. We also used the allometric relationship between field-based measurements of soil-to-leaf hydraulic conductance and laboratory-based measurements of leaf hydraulic conductance to compute the average fRleaf for 19 tree samples, which was 0.40 (95% CI = 0.29-0.56). The in situ technique produces a more accurate descriptor of fRleaf because it accounts for dynamic leaf hydraulic conductance. Both approaches demonstrate the outsized role of leaves in controlling tree hydrodynamics. A larger fRleaf may help stems from loss of hydraulic conductance. Thus, the decline in fRleaf with tree height would contribute to greater drought vulnerability in taller trees and potentially to their observed disproportionate drought mortality.

Assessment of Blue Light Phototherapy for Grover Disease: A Nonrandomized Controlled Trial.

This nonrandomized clinical trial assesses treatment of patients diagnosed with Grover disease with blue light phytotherapy for several weeks.

Review of visceral throat and chest disorders causing nonodontogenic orofacial pain.

BACKGROUND: The purpose of this narrative review was to show that referred orofacial pain can be the chief symptom or a prominent symptom of visceral diseases of the chest and throat, with implications for dental and medical practice. TYPES OF STUDIES REVIEWED: A search of PubMed was performed to identify dentally relevant clinical case reports and case series using the following terms: jaw pain, orofacial pain, toothache, temporomandibular disorders, otalgia, neuralgia, and neuropathicpain crossed with angina, myocardial infarction, carotid artery, esophagus, mediastinum, thyroid, heart, pericardium, aorta, lung, thymus gland, and stomach. RESULTS: Numerous acute, visceral disorders of the throat and chest have been reported to produce pain in the orofacial region, which may be difficult to distinguish from dental-related diseases on the basis of symptoms alone. Chest organs and structures reported to cause such pain include the heart, aorta, esophagus, stomach, lungs, and mediastinum. Throat organs and structures reported to cause pain in the orofacial region include the thyroid gland, carotid arteries, and vagus and glossopharyngeal nerves. Coronary artery diseases, aortic and carotid dissection, mediastinal tumors, subacute thyroiditis, and gastroesophageal reflux disease have a predilection for referring pain orofacially. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Misdiagnosis of referred visceral orofacial pain can lead to delayed diagnosis and unnecessary treatment. Dentists can play a key role in the management of these conditions by means of ruling out odontogenic facial pain, promptly referring patients to medical specialists, and educating patients. Future research is needed to determine the incidence and mechanism of orofacial pain in these disorders. Visceral pain referred to the orofacial region may not be as rare a phenomenon as is sometimes assumed.

P- and E- selectin in venous thrombosis and non-venous pathologies.

Venous thromboembolism is a very common and costly health problem worldwide. Anticoagulant treatment for VTE is imperfect: all have the potential for significant bleeding, and none prevent the development of post thrombotic syndrome after deep vein thrombosis or chronic thromboembolic pulmonary hypertension after pulmonary embolism. For these reasons, alternate forms of therapy with improved efficacy and decreased bleeding are needed. Selectins are a family (P-selectin, E-selectin, L-selectin) of glycoproteins that facilitate and augment thrombosis, modulating neutrophil, monocyte, and platelet activity. P- and E-selectin have been investigated as potential biomarkers for thrombosis. Inhibition of P-selectin and E-selectin decrease thrombosis and vein wall fibrosis, with no increase in bleeding. Selectin inhibition is a promising avenue of future study as either a stand-alone treatment for VTE or as an adjunct to standard anticoagulation therapies.

COVID-19 Vaccine Mandates: Impact on Radiology Department Operations and Mitigation Strategies.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) vaccine mandates are being implemented in health systems across the United States, and the impact on the radiology department workforce and operations becuase of vaccine hesitancy among health care workers is currently unknown. This article discusses the potential impact of the COVID-19 vaccine mandate on a large multicenter radiology department as well as strategies to mitigate those effects. METHODS: Weekly vaccine compliance data were obtained for employees across the entire health system from August 17, 2021, through September 13, 2021, and radiology department-specific data were extracted. Vaccine compliance data was mapped to specific radiology job titles and the five different hospital locations. RESULTS: A total of 6% of radiology department employees were not fully vaccine compliant by the initial deadline of September 10, 2021. MR technologists and radiology technology assistants had the highest initial rates of noncompliance of 37% and 38%, respectively. Vaccine noncompliance rates by the mandate deadline ranged from 0.5% to 7.0% at the five hospital sites. Only one hospital required a decrease in imaging hours of operation because of the vaccine mandate. CONCLUSION: Despite initial concerns about the impact of vaccine mandate noncompliance on departmental operations, there was ultimately little effect because of improved vaccine compliance after the mandate. Understanding individual employee and locoregional differences in vaccine compliance can help leaders proactively develop mitigation strategies to manage this new challenge during the COVID-19 pandemic.

E-selectin inhibitor is superior to low-molecular-weight heparin for the treatment of experimental venous thrombosis.

BACKGROUND: This study evaluated E-selectin inhibition with GMI-1271 (Uproleselan [GMI]) alone and in combination with the standard of care low-molecular-weight heparin (LMWH) to improve vein recanalization, decrease vein wall inflammation and protect against adverse bleeding in a primate model. We sought to examine this novel treatment of venous thrombosis. METHODS: Using a well-documented primate animal model, iliac vein thrombosis was induced by balloon occlusion of the iliac vein for 6 hours. Starting on day 2 after thrombosis, animals began treatment in two phases. In phase one, nontreated controls received no treatment (n = 5) vs animals treated with the E-selectin inhibitor GMI, 25 mg/kg, subcutaneous (SC), once daily (n = 4) for 21 days (previously published data). In phase two, animals were treated with GMI plus a combination of LMWH 1.5 mg/kg or 40 mg (GMI + LMWHc) SC once daily (n = 8) for 19 days; and animals treated with LMWH 1.5 mg/kg or 40 mg (LMWHc) SC once daily (n = 6) for 19 days. Animals were evaluated by magnetic resonance venography for vein recanalization and inflammation by gadolinium extravasation, duplex ultrasound, coagulation tests (thromboelastography, bleeding time, prothrombin time, activated partial thromboplastin time, fibrinogen) and complete blood count at baseline, days 2, 7, 14, and 21 at euthanasia. Statistical analysis included using unpaired t test with Welch's correction for direct comparisons and one-way analysis of variance for comparison between the groups. RESULTS: Percent vein recanalization by magnetic resonance venography was highest in the GMI alone group followed by GMI + LMWHc, both significantly different from control. On ultrasound examination, animals treated with GMI alone had no decrease in open vein lumen by day 21, whereas decreases were observed in groups GMI + LMWHc (-26%), LMWHc (-27%), and controls (-80%). Vein wall inflammation decreased significantly in all treated groups. Intimal fibrosis and intimal thickness was best preserved in the GMI alone group. An analysis of total vein wall collagen revealed a trend in all treatment groups of decreasing vein wall collagen. No clinically significant bleeding events were noted in any group. The LMWH groups trended to have prolonged coagulation test values, whereas E-selectin inhibition with GMI did not cause clinically significant changes in coagulation measures. CONCLUSIONS: Treatment with E-selectin inhibition results in improved vein recanalization, a decrease in vein wall inflammation and vein wall intimal thickness and fibrosis, with no changes in markers of coagulation. E-selectin inhibition with GMI alone is superior to E-selectin inhibition combined with LMWH, LMWH alone, and no treatment in this deep vein thrombosis model of iliac vein thrombosis.

Aggressive Nodular Malignant Melanoma.

A subtype of malignant melanomas, nodular melanoma often carries a poor prognosis because of local invasion and frequent distant metastasis. Here, we report a case of progressive dyspnea due to one of the largest primary melanomas in the literature to date along with management strategies and elucidate some of the reasons why patients delay seeking care.

Laser interstitial thermal therapy (LITT) for intracranial lesions: a single-institutional series, outcomes, and review of the literature.

INTRODUCTION: Laser interstitial thermal therapy (LITT) is a minimally invasive treatment method in managing primary brain neoplasms, brain metastases, radiation necrosis, and epileptogenic lesions, many of which are located in operative corridors that would be difficult to address. Although the use of lasers is not a new concept in neurosurgery, advances in technology have enabled surgeons to perform laser treatment with the aid of real-time MRI thermography as a guide. In this report, we present our institutional series and outcomes of patients treated with LITT. METHODS: We retrospectively evaluated 19 patients (age range, 28-77 years) who underwent LITT at one or more targets from 2015 to 2019. Primary endpoint observed was mean progression free survival (PFS) and overall survival (OS). RESULTS: Seven patients with glial neoplasms and 12 patients with metastatic disease were reviewed. Average hospitalization was 2.4 days. Median PFS was 7 and 4 months in the metastatic group and primary glial neoplasm group, respectively (p = 0.01). Median OS from time of diagnosis was 41 and 32 months (p = 0.02) and median OS after LITT therapy was 25 and 24 months (p = 0.02) for the metastatic and primary glial neoplasm groups, respectively. One patient experienced immediate post-procedural morbidity secondary to increased intracerebral edema peri-lesionally while one patient experienced post-operative mortality and expired secondary to hemorrhage 1-month post-procedure. Median follow-up was 10 months. CONCLUSION: Laser interstitial thermal therapy (LITT) is a safe, minimally invasive treatment method that provides surgeons with cytoreductive techniques to treat neurosurgical conditions. Both PFS and OS appear to be more favorable after LITT in patients with metastatic disease. In properly selected patients, this modality offers improved survival outcomes in conjunction with other salvage therapies.

Miniaturized electromechanical devices for the characterization of the biomechanics of deep tissue.

Evaluating the biomechanics of soft tissues at depths well below their surface, and at high precision and in real time, would open up diagnostic opportunities. Here, we report the development and application of miniaturized electromagnetic devices, each integrating a vibratory actuator and a soft strain-sensing sheet, for dynamically measuring the Young's modulus of skin and of other soft tissues at depths of approximately 1-8 mm, depending on the particular design of the sensor. We experimentally and computationally established the operational principles of the devices and evaluated their performance with a range of synthetic and biological materials and with human skin in healthy volunteers. Arrays of devices can be used to spatially map elastic moduli and to profile the modulus depth-wise. As an example of practical medical utility, we show that the devices can be used to accurately locate lesions associated with psoriasis. Compact electronic devices for the rapid and precise mechanical characterization of living tissues could be used to monitor and diagnose a range of health disorders.

A case of disseminated cryptococcus in an immunocompetent individual necessitating ventriculoperitoneal shunt.

Cryptococcosis is a rare fungal disease causes primarily by two opportunistic organisms. It is usually seen in the immunocompromised but rarely it can infect immunocompetent individuals. We present a case of disseminated cryptococcus manifesting as cryptococcal meningitis in a young immunocompetent individual that led to substantial nonobstructive hydrocephalus which required VP shunt placement.

Radiologic Manifestations of Pulmonary Vein Ablation Complications: A Pictorial Review.

In patients with atrial fibrillation refractory to drug therapy and cardioversion, pulmonary vein ablation is an alternative treatment that eradicates arrhythmogenic activity originating in the muscles of the pulmonary veins. While this procedure has a low incidence of significant complications, iatrogenic injuries are possible. Through multimodality pictorial examples utilizing computed tomography, nuclear medicine, fluoroscopy, and chest radiographs, the complications associated with pulmonary vein ablation will be reviewed. Examples of pulmonary vein stenosis, right phrenic nerve injury with associated diaphragmatic paralysis, atrioesophageal fistula, and pericardioesophageal fistula will be illustrated.

The receptive field for visceral pain referred orofacially by the vagus nerves.

BACKGROUND: The nociceptive receptive field of the vagus nerves in animals includes virtually the entire thoracic, abdominal and laryngopharyngeal regions. However, the role of the vagus nerves in the transmission of visceral pain in humans, with the exception of pain from coronary artery diseases, is believed to be insignificant. AIM: The purpose of this report is to map out the clinical visceral pain receptive field of the vagus nerves relative to its nociceptive counterpart in animals. MATERIALS AND METHODS: The PubMed database and PMC were searched for case reports of patients with orofacial pain believed by the author(s) of the article to be referred from underlying non-cardiac thoracic, laryngopharyngeal or abdominal diseases. Reports of diseases for which non-neural explanations for the orofacial spread of pain were suggested were excluded. RESULTS: A total of 52 case reports of jaw pain and/or otalgia referred from laryngopharyngeal and noncardiac thoracic sources were discovered. In addition, a multicenter prospective study found that 25.8% of more than 3,000 patients with thoracic aortic dissection experienced pain in the head and neck region. In stark contrast, no case reports of orofacially referred pain from abdominal diseases were found. DISCUSSION: The results indicate that the laryngopharyngeal and thoracic portions of the vagal receptive field are capable of referring pain orofacially while the abdominal portion is not. The roles of the somatotopic organization of the trigeminal sub nucleus caudalis and neuromodulation in this referral of pain were discussed. CONCLUSION: Referred orofacial pain can lead to delayed diagnosis and poorer outcome in visceral diseases.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Zone I Balloon Occlusion Time Affects Spinal Cord Injury in the Nonhuman Primate Model.

OBJECTIVES: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used clinically to limit torso bleeding and restore central perfusion. The objective of this study was to determine the sequelae of prolonged REBOA in a nonhuman primate animal model. SUMMARY BACKGROUND DATA: Prolonged duration of REBOA is associated with adverse clinical outcomes. Threshold occlusion values tied to relative risk have yet to be determined. METHODS: Juvenile baboons were subjected to 40% to 55% total blood volume hemorrhage to achieve profound hypotension and shock. Zone I REBOA was performed for 60 minutes to assess acute injury and survival at 4 hours (group 1; n = 7). Post-REBOA 10-day survival and complications were then compared between 60 minutes (group 2; n = 8) and 30 minutes (group 3; n = 6) REBOA animals. RESULTS: Overall survival was 20/21 (95%). IL-6 and IL-8 were elevated at 1 and 4 hours in group 1 (P = 0.005; P = 0.001). Comparing 60-minute REBOA with 30-minute REBOA, there was (1) hypertension compared with normotension (P = 0.005), (2) increased base deficit (P = 0.003), (3) elevated Troponin I (P = 0.04), and histological evidence of kidney injury (P = 0.004). In addition, group 2 demonstrated paralysis with histopathologic changes of spinal cord ischemia (SCI) in 4/8 (50%), with no SCI in group 3 (P = 0.033). CONCLUSIONS: REBOA limits mortality in the primate model of severe hemorrhagic shock. However, unopposed balloon inflation in the distal thoracic aorta for 60 minutes results in high rates of spinal cord ischemia, an effect mitigated by limiting balloon inflation to 30 minutes.

Extraosseous multiple myeloma: imaging spectrum in the abdomen and pelvis.

Multiple myeloma represents a subset of plasma cell dyscrasias characterized by the proliferation of plasma cells typically in the bone marrow, representing approximately 1% of all cancers and 15% of hematologic malignancies. Often multiple myeloma is limited to the skeletal system; however, a small percentage (<5%) of patients will develop extraosseous manifestations. We review the current WHO classification of plasma cell dyscrasias and use multimodality imaging including US, CT, MRI, and PET-CT to illustrate the spectrum of extraosseous multiple myeloma in the abdomen and pelvis. Because extraosseous multiple myeloma is associated with a poorer prognosis and decreased survival, it is important for the radiologist to become familiar with a variety of extraosseous manifestations in the abdomen and pelvis, especially in a patient with a known diagnosis of multiple myeloma and the development of an abdominal or pelvic mass.

Patients avoided important care during the early weeks of the coronavirus pandemic: diverticulitis patients were more likely to present with an abscess on CT.

PURPOSE: To evaluate the frequency with which patients with an urgent health concern, specifically diverticulitis, avoided appropriate medical care during the early weeks of the coronavirus pandemic of 2020 and to study the consequences of the resultant delay in care, the incidence of an associated abscess. METHODS: This study was institutional review board approved. Reports for CT studies with findings of newly diagnosed diverticulitis within Henry Ford Health System during the early weeks of the coronavirus pandemic of 2020 were reviewed and compared with the same time period in 2019. Total cases of diverticulitis on CT were compared, as well as the prevalence of an associated abscess. A chi-squared analysis was performed to determine the statistical significance of the percentage of patients presenting with an abscess in each year. RESULTS: During the early weeks of the coronavirus pandemic, 120 patients were identified with CT findings of newly diagnosed diverticulitis with 11.7% of those patients (14 patients) presenting with an associated abscess. During the same time period in 2019, many more CT studies with newly diagnosed diverticulitis were obtained (339), and, compared to 2020, less than half the percentage of those patients had an associated abscess (4.4% or 15 patients). CONCLUSION: Patients with urgent health concerns avoided appropriate and necessary care during the early weeks of the coronavirus pandemic. While non-COVID-19 emergency visits were diminished, patients who did present with diverticulitis were more likely to present with greater disease severity as manifested by an associated abscess. Patients must be encouraged to seek care when appropriate and need reassurance that hospitals and their emergency departments are safe to visit. Furthermore, emergency physicians and radiologists in particular should be vigilant during times when emergency volumes are low, such as a future surge in coronavirus patients, other pandemics, snow storms, and holidays as the patients who do present for care are more likely to present at later stages and with serious complications.