Lower Trapezius Tendon Transfer for Restoration of External Rotation in Brachial Plexus Birth Injury.

OBJECTIVE: Patients with brachial plexus birth injuries (BPBIs) are at risk for limitations in shoulder external rotation. The role of lower trapezius tendon transfer to restore shoulder external rotation in this population has not been well-characterized. This study aimed to evaluate the utility of lower trapezius tendon transfer for restoration of external rotation in a subset of pediatric patients. METHODS: Seventeen pediatric patients with BPBI were treated with lower trapezius tendon transfer to restore external rotation of the shoulder. Mean age at surgery was eight years, and 11 were female. Six patients had prior shoulder surgery to restore external rotation, while one had prior nerve surgery to restore shoulder function. Range of motion before lower trapezius transfer and at latest follow-up were obtained. Mean follow-up was 36 months. RESULTS: Active forward flexion did not significantly change from preoperative to final follow-up (mean, 147° and 141°; p=0.46). External rotation in adduction significantly changed from preoperative to final follow-up, (mean, 4° and 26°; p<0.001). External rotation in abduction significantly changed from preoperative to final follow-up (mean, 75° and 84°; p=0.048). Six patients (35%) had subsequent surgeries at average 17 months from this procedure. Significant univariate associations with subsequent surgery included certain intraoperative concomitant procedures-coracoid osteotomy/excision (p=0.02) and biceps tenodesis (p=0.04)-while bony glenoid augmentation/reconstruction trended toward significant association (p=0.05). CONCLUSION: Lower trapezius tendon transfer for BPBI showed a statistically significant but unlikely clinically meaningful improvement in external rotation with a high rate of reoperation.

Patterns of Rising HIV Positivity in Northern Madagascar: Evidence of an Urgent Public Health Concern.

Despite over two decades of progress against HIV/AIDS in adjacent sub-Saharan Africa, HIV rates and deaths due to AIDS are exponentially rising in Madagascar. Furthermore, a growing body of evidence suggests that, due to a scarcity of general-population screening data, even the startling increase demonstrated by official models vastly underestimates the true population prevalence of HIV. We aimed to implement a real-world HIV screening and treatment protocol to serve a general population stemming from across northern Madagascar. In collaboration with the Malagasy Ministry of Health, we provided point-of-care HIV screening and confirmatory testing for over 1000 participants from 73 towns, villages, and cities. We recorded an overall HIV prevalence of 2.94%. Notably, we observed a 13.1% HIV prevalence rate among urban populations and showed that proximity to a major route of travel was significantly associated with HIV risk. We also observed a link between HIV risk and various occupations, including those associated with increased mobility (such as mining). Importantly, all HIV-positive individuals were initiated on antiretroviral therapy in concordance with local health authorities. To our knowledge, this study marks the largest primary test data-based HIV study to date among Madagascar's general population, showing a greatly higher HIV prevalence (2.9%) than previously reported modeling-based figures (0.4%). Our rates aligned with the pattern of higher prevalence demonstrated in smaller general-population screening studies occurring more commonly prior to political strife in the mid-2000s. These findings demonstrate evidence of a growing HIV epidemic in northern Madagascar and underscore the need for future investment into more comprehensive HIV screening and control initiatives in Madagascar.

Vulvar glomangioma: A case report and literature review.

GLMN is a gene that encodes a critical protein necessary for normal vascular development. Mutations of GLMN predispose individuals to development of glomangiomas, with nearly 100% penetrance by age 30. Glomangiomas are tumors of the glomus body, a thermoregulatory arterial-venous shunt composed of modified smooth muscle cells. Vulvar glomangioma is an exceedingly rare cause of chronic pelvic pain, that may be easily confused for other conditions such as Bartholin's gland abscess or deep angiomxyomas, thereby delaying diagnosis and treatment. Glomangiomas have characteristic pathologic and imaging findings which may aid diagnosis. We herein describe the case of a 24-year-old female who developed chronic pelvic pain in the setting of a vulvar glomangioma. We further delineate the magnetic resonance imaging and biopsy findings critical to her diagnosis, and the appropriate steps taken for surgical management. She was found to harbor a heterozygous GLMN mutation. To the best of our knowledge, this is the first description of such a case in the medical literature.

Clear cell adenocarcinoma arising from anterior abdominal wall cesarean section scar endometriosis treated with excision and the addition of Trastuzumab for adjuvant chemotherapy: A case report.

Abdominal wall endometriosis with subsequent transformation to clear cell carcinoma is quite rare. The pathogenesis and pattern of this transformation is not well known; hence evaluation and management guidelines are not well established. We highlight a case of clear cell adenocarcinoma arising from the anterior abdominal wall in a previous cesarean section scar treated with excision and the unique addition of Trastuzumab for adjuvant chemotherapy.

Iatrogenic Hypotension Induced by the Improper Treatment of Normal Grief.

We report the case of a 28-year-old male in rural Madagascar with iatrogenic hypotension induced by improper treatment of a normal grief response. The man lost both of his children in the spring of 2019 during a measles outbreak that infected at minimum 152,000 individuals on the island. After developing symptoms of chest pain, intermittent tachycardia, and widespread pain when he would think of his children in the weeks following their loss, he was prescribed gabapentin, lisinopril, and metoprolol by a general practice nurse. He subsequently developed dizziness, lightheadedness, and fatigue. After visiting Mada Clinics two weeks later, all medications were stopped, and the man's symptoms resolved. This case demonstrates the effects of a lack of available mental health care in Madagascar, a country with sixteen available psychiatrists for a rapidly expanding population of over 26 million people.

Pathogenesis and pathways: nonalcoholic fatty liver disease & alcoholic liver disease.

Alcoholic liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) account for the majority of hepatic morbidity and deaths due to cirrhosis in the United States. ALD is an umbrella term for a number of conditions linked to excessive alcohol consumption including simple steatosis, cirrhosis, acute alcoholic hepatitis (AH) with or without cirrhosis, and hepatocellular carcinoma (HCC) as a complication of cirrhosis. Although it presents with histological features resembling alcohol-induced liver injury, NAFLD occurs in patients with little or no history of alcohol consumption. NAFLD is a broad-spectrum term used to describe anything from fat accumulation in hepatocytes without inflammation or fibrosis (simple hepatic steatosis) to hepatic steatosis with a necroinflammatory component (steatohepatitis) with or without associated fibrosis. The pathogenesis is not fully understood for either disease. Development of severe liver disease is highly variable amongst chronic abusers of alcohol. Sex, age, genetics, host microbiome, and behavior are all factors linked to the development of ALD. These factors also contribute to NAFLD, but by contrast, insulin resistance is widely believed to be the main driver of nonalcoholic hepatic steatosis. The mechanism behind the transition from nonalcoholic steatosis to steatohepatitis remains a matter of debate with insulin resistance, oxidative injury, hepatic iron, gut hormones, antioxidant deficiency, and host microbiome all suspected to play part of the role.