Postoperative Imaging of Endometriosis.

Endometriosis is a highly prevalent disease that affects 10%-15% of women of reproductive age worldwide and is mainly associated with chronic pelvic pain and infertility. With the widespread use of imaging for the diagnosis and monitoring of endometriosis, combined with the ability of surgery to eradicate the disease and address infertility, there has been a significant increase in recent years in imaging examinations for postoperative evaluation of endometriosis. US and MRI are used not only to help diagnose and map endometriosis but also to evaluate refractory symptoms, residual lesions, and complications at posttreatment assessment. Knowledge of surgical techniques and recognition of expected postoperative imaging findings are crucial to differentiate postoperative changes from residual disease and/or recurrence. The authors discuss imaging aspects of postoperative endometriosis, with an emphasis on the imaging approach, comprehension of surgical techniques, recognition of the expected findings, possible complications, and analysis of residual disease or recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by VanBuren in this issue. The slide presentation from the RSNA Annual Meeting is available for this article.

Stroke Unit as an alternative to Intensive Care Unit for initial hospital admission of low-grade non-aneurysmal subarachnoid haemorrhage: A safety and cost-minimisation analysis.

INTRODUCTION: Stroke Units (SU) have been suggested as an alternative to Intensive Care units (ICU) for initial admission of low-grade non-aneurysmal spontaneous subarachnoid haemorrhage (naSAH). We hypothesised that the incidence of in-hospital complications and long-term clinical outcomes in low-grade naSAH patients would be comparable in both settings, and that a cost-minimisation analysis would favour the use of SU. PATIENTS AND METHODS: Retrospective, single-centre study at a third-level stroke-referral hospital, including low-grade spontaneous naSAH patients with WFNS 1-2. Primary outcomes were death and functional status at 3 months. Secondary outcomes were incidence of in-hospital major neurological and systemic complications. Additionally, a cost-minimisation analysis was conducted to estimate the average cost savings that could be achieved with the most efficient approach. RESULTS: Out of 96 naSAH patients, 30 (31%) were initially admitted to ICU and 66 (69%) to SU. Both groups had similar demographic and radiological features except for a higher proportion of WFNS 2 in ICU subgroup. There were no statistically significant differences between ICU and SU-managed subgroups in death rate (2 (7%) and 1 (2%), respectively), functional outcome at 90 days (28 (93%) and 61 (92%) modified Rankin Scale 0-2) or neurological and systemic in-hospital complications. Cost-minimisation analysis demonstrated significant monetary savings favouring the SU strategy. DISCUSSION AND CONCLUSION: Initial admission to the SU appears to be a safe and cost-effective alternative to the ICU for low-grade naSAH patients, with comparable clinical outcomes and a reduction of hospitalisation-related costs. Prospective multicenter randomised studies are encouraged to further evaluate this approach.

Effect of operative time in outcomes following surgical fixation of hip fractures: a multivariable regression analysis of 35,710 patients.

BACKGROUND: Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures (n = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes. RESULTS: Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality. DISCUSSION: Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered.

Aneurysmal subarachnoid haemorrhage: Volumetric quantification of the blood distribution pattern to accurately predict the ruptured aneurysm location.

BACKGROUND: In spontaneous subarachnoid haemorrhage (SAH) accurate determination of the bleeding source is paramount to guide treatment. Traditionally, the bleeding pattern has been used to predict the aneurysm location. Here, we have tested a software-based tool, which quantifies the volume of intracranial blood and stratifies it according to the regional distribution, to predict the location of the ruptured aneurysm. METHODS: A consecutive series of SAH patients admitted to a single tertiary centre between 2012-2018, within 72 h of onset, harbouring a single intracranial aneurysm. A semi-automatized method of blood quantification, based on the relative density increase, was applied to initial non-contrast CTs. Five regions were used to define the bleeding patterns and to correlate them with aneurysm location: perimesencephalic, interhemispheric, right/left hemisphere and intraventricular. RESULTS: 68 patients were included for analysis. There was a strong association between the distribution of blood and the aneurysm location (p < 0.001). In particular: ACom and interhemispheric fissure (p < 0.001), MCA and ipsilateral hemisphere (p < 0.001), ICA and ipsilateral hemisphere and perimesencephalic cisterns (p < 0.001), PCom and hemispheric, perimesencephalic and intraventricular (p = 0.019), and PICA and perimesencephalic and intraventricular (p < 0.001). The internal diagnostic value was high (AUROC ≥ 0.900) for these locations. CONCLUSION: Regional automatised volumetry seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid spaces. This tool accurately predicts the location of the ruptured aneurysm; its use may be prospectively considered in the emergency setting when speed and simplicity are attained.

Successful Transplantation of a Liver from a Donor with HELLP Syndrome Undergoing Hypothermic Oxygenated Machine Perfusion (HOPE) Prior to Implantation.

BACKGROUND Liver transplantation (LT) has become the treatment of choice for patients with end-stage liver disease (ESLD). The organ shortage forced clinicians to use livers from donors with certain risk factors, so-called extended-criteria donor (ECD) organs. Hypothermic oxygenated machine perfusion (HOPE) is an alternative to conventional static cold storage and reduces early allograft injury in ECD organs. In this article we present the case of a 45-year-old man with hepatitis B virus (HBV)-associated cirrhosis and hepatocellular carcinoma (HCC) who underwent successful liver transplantation supported by pretransplant hypothermic oxygenated machine perfusion (HOPE) from a 34-year-old extended-criteria donor (ECD) with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. CASE REPORT Liver transplantation was scheduled for a 45-year-old man with hepatocellular carcinoma (HCC) due to hepatitis B virus-induced liver cirrhosis. The organ donor was a 34-year-old woman who had developed intracerebral hemorrhage and brain death due to HELLP syndrome after delivery. Compared to the day of admission to the intensive care unit, a decrease in the donor's transaminases was observed prior to organ procurement. Before transplantation, HOPE was conducted after regular back-table preparation of the graft. LT was performed according to the standard surgical techniques and a standardized immunosuppressive regimen was conducted. In the post-transplant period, transaminases peaked directly after the operation and normalized after 1 week. No major surgical complications occurred. The patient was discharged after a 24-day hospital stay with normal liver function. CONCLUSIONS This case report supports the benefits of using HOPE in ECD organs and it should be considered in livers of donors with HELLP syndrome to improve post-transplant outcome.

MicroRNA cerebrospinal fluid profile during the early brain injury period as a biomarker in subarachnoid hemorrhage patients.

Introduction: Delayed cerebral ischemia (DCI) is a dreadful complication present in up to 30% of patients with spontaneous subarachnoid hemorrhage (SAH). Indeed, DCI is one of the main causes of long-term disability in SAH, yet its prediction and prevention are troublesome in poor-grade SAH cases. In this prospective study, we explored the potential role of micro ribonucleic acid (microRNA, abbreviated miRNAs)-small non-coding RNAs involved in clue gene regulation at the post-transcriptional level-as biomarkers of neurological outcomes in SAH patients. Methods: We analyzed the expression of several miRNAs present in the cerebrospinal fluid (CSF) of SAH patients during the early stage of the disease (third-day post-hemorrhage). NanoString Technologies were used for the characterization of the CSF samples. Results: We found an overexpression of miRNAs in the acute stage of 57 SAH in comparison with 10 non-SAH controls. Moreover, a differential expression of specific miRNAs was detected according to the severity of clinical onset, but also regarding the development of DCI and the midterm functional outcomes. Conclusion: These observations reinforce the potential utility of miRNAs as prognostic and diagnostic biomarkers in SAH patients. In addition, the identification of specific miRNAs related to SAH evolution might provide insights into their regulatory functions of pathophysiological pathways, such as the TGF-ß inflammatory pathway and blood-brain barrier disruption.

Clinical relevance of glucose metrics during the early brain injury period after aneurysmal subarachnoid hemorrhage: An opportunity for continuous glucose monitoring.

Hyperglycaemia, hypoglycaemia and higher glucose variability during the Early Brain Injury (EBI) period of aneurysmal subarachnoid hemorrhage (aSAH) have been associated with poor clinical outcome. However, it is unclear whether these associations are due to direct glucose-driven injury or if hyperglycaemia simply acts as a marker of initial severity. Actually, strict glucose control with intensive insulin therapy has not been demonstrated as an effective strategy for improving clinical outcomes after aSAH. Currently published studies describing an association between hyperglycaemia and prognosis in aSAH patients have been based on isolated glucose measurements and did not incorporate comprehensive dynamic evaluations, such as those derived from subcutaneous continuous glucose monitoring devices (CMG). Arguably, a more accurate knowledge on glycaemic patterns during the acute phase of aSAH could increase our understanding of the relevance of glycaemia as a prognostic factor in this disease as well as to underpin its contribution to secondary focal and diffuse brain injury. Herein, we have summarized the available evidence on the diagnostic and prognostic relevance of glucose metrics during the acute phase of cerebrovascular diseases, focusing in the EBI period after aSAH. Overall, obtaining a more precise scope of acute longitudinal glucose profiles could eventually be useful for improving glucose management protocols in the setting of acute aSAH and to advance toward a more personalized management of aSAH patients during the EBI phase.

Occurrence of Curvularia pisi and C. muehlenbeckiae Causing Leaf Spot on Guar (Cyamopsis tetragonoloba) in Mexico.

Cyamopsis tetragonoloba (Fabaceae family), known as guar or clusterbean, is a drought-tolerant annual legume cultivated on a commercial scale focused on industrial gum production. In September 2021, symptoms of leaf spot were observed on guar plants in several commercial fields located at Guasave, Sinaloa, Mexico. Symptoms included round to oval, light brown lesions with dark margins. The disease incidence was estimated to be up to 30% in five fields. Curvularia-like colonies were consistently isolated, and 12 monoconidial isolates were obtained. Two representative isolates were selected to use downstream and were deposited in the Culture Collection of Phytopathogenic Fungi of the Faculty of Agriculture of Fuerte Valley at the Sinaloa Autonomous University under Accession FAVF643 and FAVF645. On potato dextrose agar (PDA), colonies of both isolates FAVF643 (pale brown margin) and FAVF645 (lobate edge) were dark brown. Conidiophores of both isolates FAVF643 (paler towards apex and 76 to 191 × 3.5 to 5.2 µm) and FAVF645 (80 to 260 × 3.9 to 5.1 µm) were mostly straight, pale brown to dark brown, septate, and simple to branched. Conidia of both isolates FAVF643 (19.9 to 33.3 × 8.8 to 13.5 µm) and FAVF645 (18.5 to 27.1 × 9.1 to 13.1 µm) were curved, rarely straight, brown, with apical and basal cells paler than middle cells being pale brown, and 3-distoseptate. Morphology of both isolates FAVF643 and FAVF645 was consistent with that described for Curvularia (Marin-Felix et al. 2017; 2020). For phylogenetic identification, total DNA was extracted and PCR products sequenced from ITS5/ITS4 primers -the internal transcribed spacer (ITS) region (White et al. 1990) and GPD1/GPD2 - partial sequences of glyceraldehyde-3-phosphate dehydrogenase (gpdh) gene amplification. A phylogenetic tree based on Maximum likelihood including published ITS and gpdh for Curvularia spp. was constructed. Phylogenetic analyses showed that isolate FAVF643 grouped with the type strain C. pisi (CBS190.48) sequence, and the isolate FAVF645 grouped with the type strain C.muehlenbeckiae (CBS144.63) sequence. The resulting sequences were deposited in GenBank as: C. pisi OM802153 (ITS); OM835758 (gpdh), and C. muehlenbeckiae OM802154 (ITS); OM835759 (gpdh). The pathogenicity was verified on healthy guar plants. For each isolate, five plants were inoculated by spraying a conidial suspension (1 × 106 spores/ml) onto leaves until runoff. Five plants sprayed with sterile distilled water served as controls. All plants were kept in a moist chamber for two days, and subsequently transferred to a greenhouse for 12 days at temperatures ranging from 26 to 32°C. All inoculated leaves exhibited necrotic lesions with a dark margin 10 days after inoculation, whereas control plants remained symptomless. The fungi were consistently re-isolated from the diseased leaves and found to be morphologically identical to the isolates used for inoculation, fulfilling Koch´s postulates. Curvularia lunata had been reported as the causal agent of leaf spot on guar in India (Chand and Verma 1968); however, to our knowledge, this is the first report of C. pisi and C. muehlenbeckiae causing leaf spot on guar in Mexico and worldwide.

Structure-activity relationships reveal a 2-furoyloxychalcone as a potent cytotoxic and apoptosis inducer for human U-937 and HL-60 leukaemia cells.

Synthetic flavonoids with new substitution patterns have attracted attention as potential anticancer drugs. Here, twelve chalcones were synthesized and their antiproliferative activities against five human tumour cells were evaluated. This series of chalcone derivatives was characterized by the presence of an additional aromatic or heterocyclic ring linked by an ether, in the case of a benzyl radical, or an ester or amide functional group in the case of a furoyl radical. In addition, the influence on cytotoxicity by the presence of one or three methoxy groups or a 2,4-dimethoxy-3-methyl system on the B ring of the chalcone scaffold was also explored. The results revealed that the most cytotoxic chalcones contain a furoyl substituent linked by an ester or an amide through the 2'-hydroxy or the 2'-amino group of the A ring of the chalcone skeleton, with IC50 values between 0.2 ±â€¯0.1 µM and 1.3 ±â€¯0.1 µM against human leukaemia cells. The synthetic chalcone 2'-furoyloxy-4-methoxychalcone (FMC) was, at least, ten-fold more potent than the antineoplastic agent etoposide against U-937 cells and displayed less cytotoxicity against human peripheral blood mononuclear cells. Treatment of U-937 and HL-60 cells with FMC induced cell cycle arrest at the G2-M phase, an increase in the percentage of sub-G1 and annexin-V positive cells, the release of mitochondrial cytochrome c, activation of caspase and poly(ADP-ribose) polymerase cleavage. In addition, it inhibited tubulin polymerization in vitro in a concentration dependent manner. Cell death triggered by this chalcone was decreased by the pan-caspase inhibitor z-VAD-fmk and was dependent of the generation of reactive oxygen species. We conclude that this furoyloxychalcone may be useful in the development of a potential anti-leukaemia strategy.

Factores limitantes del rendimiento académico en residentes de la especialidad de Estomatología General Integral

RESUMEN Fundamento Los resultados académicos tienen gran relevancia en la etapa de postgrado del profesional de la salud, al ser determinantes en su ubicación laboral y excelencia en el desempeño profesional. Por ello, resulta provechoso el estudio de los factores que pudieran limitar el rendimiento académico en dicho contexto. Objetivo caracterizar los factores limitantes del desempeño académico de los residentes de Estomatología General Integral durante los exámenes de promoción. Métodos se realizó un estudio descriptivo transversal, con la participación de residentes (n=29) de la especialidad de Estomatología General Integral, en el periodo de examen de promoción en los meses de junio (para segundo año) y julio (para primer año) de 2020, en el municipio de Campechuela, provincia de Granma. Se aplicaron cuestionario y entrevista a residentes y profesores del tribunal examinador, respectivamente. Se incluyeron como variables del estudio elementos intrísecos y extrínsecos, la situación socio-éconómica y las manifestaciones de estrés. Resultados el 82,76 % identificó a la falta de sistematicidad en el estudio como elemento responsable de los resultados negativos; y el 100 % refirió haber sentido ansiedad, cansancio o agotamiento; en este aspecto, el tribunal constató ansiedad en el 100 % de los residentes, y cansancio o agotamiento en el 79,31 %. Conclusión cuestiones como el nivel económico bajo, y la convivencia con personas enfermas resultaron de las más frecuentes entre las percibidas como factores limitantes del rendimiento académico; sin embargo, otros elementos de carácter subjetivo y mejorables a través del esfuerzo individual, se mostraron en mayor medida aún.

ABSTRACT Background The academic results have great relevance in the postgraduate stage of the health professional, as they are determinant in their work location and excellence in professional performance. Therefore, it is useful to study the factors that could limit academic performance in this context. Objective to characterize the limiting factors of the Comprehensive General Stomatology residents academic performance during the promotion test. Methods a cross-sectional descriptive study was carried out, with the participation of residents (n=29) of the Comprehensive General Stomatology specialty, during the promotion examination in June (for the second year) and July (for the first year) of 2020, in the Campechuela municipality, Granma province. Questionnaire and interview were applied to residents and professors of the examining board, respectively. Intrinsic and extrinsic elements, socioeconomic status, and stress manifestations were included as study variables. Results 82.76% identified the lack of systematicity in the study as the element responsible for the negative results; and 100 % reported having felt anxiety, tiredness or exhaustion; in this regard, the court found anxiety in 100 % of the residents, and tiredness or exhaustion in 79.31 %. Conclusion issues such as low economic level, and living with sick people were the most frequent among those perceived as limiting factors of academic performance; however, other subjective elements that could be improved through individual effort were shown to an even greater extent.

Standardized quantification of biofilm in a novel rabbit model of periprosthetic joint infection.

Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty. The underlying pathogenesis involves the formation of bacterial biofilm that protects the pathogen from the host immune response and antibiotics, making eradication difficult. The aim of this study was to develop a rabbit model of knee PJI that would allow reliable biofilm quantification and permit the study of treatments for PJI. In this work, New Zealand white rabbits ( n = 19 ) underwent knee joint arthrotomy, titanium tibial implant insertion, and inoculation with Xen36 (bioluminescent Staphylococcus aureus) or a saline control after capsule closure. Biofilm was quantified via scanning electron microscopy (SEM) of the tibial explant 14 d after inoculation ( n = 3 noninfected, n = 2 infected). Rabbits underwent debridement, antibiotics, and implant retention (DAIR) ( n = 6 ) or sham surgery ( n = 2 noninfected, n = 6 infected) 14 d after inoculation, and they were sacrificed 14 d post-treatment. Tibial explant and periprosthetic tissues were examined for infection. Laboratory assays supported bacterial infection in infected animals. No differences in weight or C-reactive protein (CRP) were detected after DAIR compared to sham treatment. Biofilm coverage was significantly decreased with DAIR treatment when compared with sham treatment (61.4 % vs. 90.1 %, p < 0 .0011) and was absent in noninfected control explants. In summary, we have developed an experimental rabbit hemiarthroplasty knee PJI model with bacterial infection that reliably produces quantifiable biofilm and provides an opportunity to introduce treatments at 14 d. This model may be used to better understand the pathogenesis of this condition and to measure treatment strategies for PJI.

Increased Joint Space Narrowing After Arthroscopic Partial Meniscectomy: Data From the Osteoarthritis Initiative.

BACKGROUND: Arthroscopic partial meniscectomy (APM) is widely performed and remains an important therapeutic option for patients with a meniscal tear. However, it is debated whether or not APM accelerates the progression of osteoarthritis (OA) in the long term. PURPOSE/HYPOTHESIS: The purpose was to compare the progression of OA measured by the change in tibiofemoral joint space width (JSW)-a quantitative measure of OA radiographic severity-across 3 groups with a midterm follow-up: (1) patients undergoing APM; (2) those with a meniscal tear treated nonoperatively; and (3) those without a tear. We hypothesized that the reduction in JSW would be greatest in patients undergoing APM and least in those patients without a tear. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Using the Osteoarthritis Initiative cohort, a total of 144 patients were identified that underwent APM with at least 12 months of follow up and without previous knee surgery. Those with a meniscal tear who did not have APM (n = 144) and those without a tear (n = 144) were matched to patients who had APM by sex, age, Kellgren-Lawrence (KL) grade, and follow up time. Participants underwent magnetic resonance imaging at baseline. Knee radiographs to assess JSW were collected annually or biannually. The change in minimum medial compartment JSW was calculated using a validated automated method. A piecewise linear mixed effects model was constructed to examine the relationship between JSW decline over time and treatment group-adjusting for age, body mass index, smoking status, KL grade, and baseline JSW. RESULTS: All groups had comparable baseline JSW-ranging from 4.33 mm to 4.38 mm. The APM group had a rate of JSW decline of -0.083 mm/mo in the first 12 months and -0.014 mm/mo between 12 and 72 months. The rate of JSW decline in the APM group was approximately 27 times greater in the first 12 months than that in the nonsurgical group (-0.003 mm/mo) and 5 times greater than that in the no tear group (-0.015 mm/mo); however, there was no significant difference between groups for 12 to 72 months (nonsurgical group: -0.009 mm/mo; no tear group: -0.010 mm/mo). The adjusted JSW in the APM group was 4.38 mm at baseline and decreased to 2.57 mm at 72 months; the JSW in the nonsurgical group declined from 4.31 mm to 3.73 mm, and in the no tear group it declined from 4.33 mm to 3.54 mm. There was a statistically significant difference in JSW change between baseline and 72 months for the APM group compared with the other groups (P < .001), but not between the nonsurgical and no tear groups (P = .12). CONCLUSION: In the first postoperative year, APM results in a faster rate of joint space narrowing compared with knees undergoing nonsurgical management of meniscal tears. Thereafter, there are comparable rates of OA progression regardless of the chosen management. APM results in a persistent decrease in JSW over at least 72 months. An untreated meniscal tear does not contribute to radiographic progression-assessed by JSW-as compared with an intact meniscus.

Bowel Obstruction Due to Stenotic Sigmoid Colon Cancer in a 32-Year-Old Patient Presenting in the Third Trimester of Pregnancy: A Case Report of an Interval Surgical Approach.

BACKGROUND Colorectal cancer among pregnant women is a rare entity. If colon cancer is suspected during pregnancy, the diagnosis is a therapeutic challenge that should be managed by a multidisciplinary team of specialists. Standardized therapeutic models do not exist. In this article we present a case of a pregnant patient with stenotic sigmoid colon adenocarcinoma. We describe the interdisciplinary treatment and the 2-step surgical approach used during pregnancy. CASE REPORT A 32-year-old women in week 28.8 of pregnancy was admitted to the Department of Gynecology and Obstetrics, meeting the standard pregnancy criteria of constipation. After a week of unsuccessful conservative treatment, the patient underwent magnetic resonance imaging (MRI), which disclosed a stenosed segment in the sigmoid colon. After an emergency colonoscopy with biopsy sampling, histological analysis confirmed sigmoid adenocarcinoma. In a multidisciplinary consultation of specialists, in which neonatological and oncological aspects were considered, a 2-step surgical plan was established. In the first step (gestational week 29.8), a loop transverse colostomy with intestinal decompression was performed. In the second step (gestational week 32.8), an elective primary caesarean section followed by open oncological sigmoid resection was performed. No postoperative complications occurred in either step. The neonate was healthy and had a birth weight appropriate for the gestational age. CONCLUSIONS In cases of colorectal cancer during pregnancy, staged surgical approaches should be considered to reduce maternal and fetal morbidity.

Current treatments for biofilm-associated periprosthetic joint infection and new potential strategies.

Periprosthetic joint infection (PJI) remains a devastating complication after total joint arthroplasty. Bacteria involved in these infections are notorious for adhering to foreign implanted surfaces and generating a biofilm matrix. These biofilms protect the bacteria from antibiotic treatment and the immune system making eradication difficult. Current treatment strategies including debridement, antibiotics, and implant retention, and one- and two-stage revisions still present a relatively high overall failure rate. One of the main shortcomings that has been associated with this high failure rate is the lack of a robust approach to treating bacterial biofilm. Therefore, in this review, we will highlight new strategies that have the potential to combat PJI by targeting biofilm integrity, therefore giving antibiotics and the immune system access to the internal network of the biofilm structure. This combination antibiofilm/antibiotic therapy may be a new strategy for PJI treatment while promoting implant retention.

CSF Biomarkers in COVID-19 Associated Encephalopathy and Encephalitis Predict Long-Term Outcome.

Patients with coronavirus disease 2019 (COVID-19) frequently develop acute encephalopathy and encephalitis, but whether these complications are the result from viral-induced cytokine storm syndrome or anti-neural autoimmunity is still unclear. In this study, we aimed to evaluate the diagnostic and prognostic role of CSF and serum biomarkers of inflammation (a wide array of cytokines, antibodies against neural antigens, and IgG oligoclonal bands), and neuroaxonal damage (14-3-3 protein and neurofilament light [NfL]) in patients with acute COVID-19 and associated neurologic manifestations (neuro-COVID). We prospectively included 60 hospitalized neuro-COVID patients, 25 (42%) of them with encephalopathy and 14 (23%) with encephalitis, and followed them for 18 months. We found that, compared to healthy controls (HC), neuro-COVID patients presented elevated levels of IL-18, IL-6, and IL-8 in both serum and CSF. MCP1 was elevated only in CSF, while IL-10, IL-1RA, IP-10, MIG and NfL were increased only in serum. Patients with COVID-associated encephalitis or encephalopathy had distinct serum and CSF cytokine profiles compared with HC, but no differences were found when both clinical groups were compared to each other. Antibodies against neural antigens were negative in both groups. While the levels of neuroaxonal damage markers, 14-3-3 and NfL, and the proinflammatory cytokines IL-18, IL-1RA and IL-8 significantly associated with acute COVID-19 severity, only the levels of 14-3-3 and NfL in CSF significantly correlated with the degree of neurologic disability in the daily activities at 18 months follow-up. Thus, the inflammatory process promoted by SARS-CoV-2 infection might include blood-brain barrier disruption in patients with neurological involvement. In conclusion, the fact that the levels of pro-inflammatory cytokines do not predict the long-term functional outcome suggests that the prognosis is more related to neuronal damage than to the acute neuroinflammatory process.

Clinically reversible ustekinumab-induced encephalopathy: case report and review of the literature.

Ustekinumab, a monoclonal antibody against interleukin (IL)-12 and IL-23 approved for the treatment of Crohn's disease, has shown to be an effective therapy with a favourable safety profile. Clinical trials and real-world studies have reported very few neurological adverse events, including posterior reversible encephalopathy syndrome, idiopathic intracranial hypertension and headache. We describe the case of a 48-year-old man with Crohn's disease who initiated treatment with ustekinumab on top of ongoing treatment with methotrexate 25 mg/week who presented with an acute-onset encephalopathy that rapidly evolved to severe tetraparesis and akinetic mutism, associated with extensive leukoencephalopathy and restricted diffusion on brain magnetic resonance imaging (MRI), 1 month after the second dose of ustekinumab. Comprehensive in-patient diagnostic testing ruled out vascular, demyelinating, metabolic, tumoral and infectious etiologies. Brain biopsy showed patchy infiltrates of foamy histiocytes with perivascular distribution, associated with edema, diffuse astrocytic gliosis and focal perivascular axonal destruction without demyelination, and ustekinumab-induced neurotoxicity was suspected. After drug discontinuation, the patient presented a complete clinical recovery despite the persistence of leukoencephalopathy. In conclusion, in an era in which biological therapies are continually evolving and expanding, knowledge about the potential neurotoxicity of these new therapies and their management becomes crucial. Although ustekinumab-induced encephalopathy is uncommon, the recognition of this potentially serious side effect is important because prompt withdrawal is associated with a favourable outcome. Whether methotrexate played an additional contributing role is currently unknown, but it is a factor that should be considered.

Aquaporin-4-Positive Triple-Negative Breast Cancer Presenting with Paraneoplastic Neuromyelitis Optica Spectrum Disorder.

INTRODUCTION: Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory central nervous system disorder that preferentially affects the optic nerve and the spinal cord. Although NMOSD is more commonly an idiopathic autoimmune condition associated with antibodies against aquaporin-4 (AQP4)-IgG, the disease may also occur as a paraneoplastic syndrome in rare instances. In these cases, the expression of AQP4 by the tumor is likely the trigger of the autoimmune response. CASE PRESENTATION: We describe the case of a 32-year-old woman who presented with progressive tetraparesis, cranial involvement, respiratory failure, and spinal cord MRI compatible with longitudinally extensive transverse myelitis, few days after being diagnosed with a T3N1M0 triple-negative right breast cancer. Due to the history of concurrent breast cancer and after ruling out metastatic spinal cord involvement, the possibility of a paraneoplastic origin was raised. AQP4-IgG were found in the serum and CSF by cell-based assay, confirming the diagnosis of NMOSD. The patient was treated with corticosteroids, plasma exchange, and rituximab. Concomitantly, breast cancer therapy was started with an adapted neoadjuvant chemotherapy scheme based on carboplatin and paclitaxel. An initial slight improvement slowed down; so, a right mastectomy with lymphadenectomy was performed. Expression of AQP4 was demonstrated in the tumor. The patient presented a significant neurological improvement after combined treatment regaining muscular balance and strength in upper and lower extremities. CONCLUSION: NMOSD may have a paraneoplastic origin associated with breast cancer and the importance of its early detection since the combination of tumoral and immunosuppressive therapy may improve the patient's prognosis.

Preoperative Colonization With Staphylococcus Aureus in THA Is Associated With Increased Length of Stay.

BACKGROUND: Staphylococcus aureus is a common organism implicated in prosthetic joint infection after THA and TKA, prompting preoperative culturing and decolonization to reduce infection rates. It is unknown whether colonization is associated with other noninfectious outcomes of THA or TKA. QUESTIONS/PURPOSES: (1) What is the association between preoperative S. aureus colonization (methicillin-sensitive S. aureus [MSSA] and methicillin-resistant S. aureus [MRSA]) and the noninfectious outcomes (discharge destination, length of stay, Hip/Knee Disability and Osteoarthritis Outcome Score [HOOS/KOOS] pain score, HOOS/KOOS physical function score, 90-day readmission, and 1-year reoperation) of THA and TKA? (2) What factors are associated with colonization with S. aureus ? METHODS: Between July 2015 and March 2019, 8078 patients underwent primary THA in a single healthcare system, and 17% (1382) were excluded because they were not tested preoperatively for S. aureus nasal colonization, leaving 6696 patients in the THA cohort. Between June 2015 and March 2019, 9434 patients underwent primary TKA, and 12% (1123) were excluded because they were not tested for S. aureus colonization preoperatively, leaving 8311 patients in the TKA cohort. The goal of the institution's standardized care pathways is to test all THA and TKA patients preoperatively for S. aureus nasal colonization; the reason the excluded patients were not tested could not be determined. Per institutional protocols, all patients were given chlorhexidine gluconate skin wipes to use on the day before and the day of surgery, and patients with positive S. aureus cultures were instructed to use mupirocin nasal ointment twice daily for 3 to 5 days preoperatively. Adherence to these interventions was not tracked, and patients were not rescreened to test for S. aureus control. The minimum follow-up time for each outcome and the percentage of the cohort lost for each was: for discharge destination, until discharge (0 patients lost); for length of stay, until discharge (0.06% [4 of 6696] lost in the THA group and 0.01% [1 of 8311] lost in the TKA group); for HOOS/KOOS pain score, 1 year (26% [1734 of 6696] lost in the THA group and 24% [2000 of 8311] lost in the TKA group); for HOOS/KOOS physical function, 1 year (33% [2193 of 6696] lost in the THA group and 28% [2334 of 8311] lost in the TKA group); for 90-day readmission, 90 days (0.06% [4 of 6696] lost in the THA group and 0.01% [1 of 8311] lost in the TKA group); and for 1-year reoperation, 1 year (30% [1984 of 6696] lost in the THA group and 30% [2475 of 8311] lost in the TKA group). Logistic regression models were constructed to test for associations between MSSA or MRSA and nonhome discharge, length of stay greater than 1 day, improvement in the HOOS/KOOS pain subscale (≥ the minimum clinically important difference), HOOS/KOOS physical function short form (≥ minimum clinically important difference), 90-day readmission, and 1-year reoperation. We adjusted for patient-related and hospital-related factors, such as patient age and hospital site. Variable significance was assessed using the likelihood ratio test with a significance level of p < 0.05. To assess factors associated with S. aureus colonization, we constructed a logistic regression model with the same risk factors. RESULTS: Among the THA cohort, after controlling for potentially confounding variables such as patient age, smoking status, and BMI, S. aureus colonization was associated with length of stay greater than 1 day (MSSA: odds ratio 1.32 [95% CI 1.08 to 1.60]; MRSA: OR 1.88 [95% CI 1.24 to 2.85]; variable p < 0.001 by likelihood ratio test) but not the other outcomes of THA. Male sex (OR 1.26 [95% CI 1.09 to 1.45]; p = 0.001) and BMI (OR 1.02 for a one-unit increase over median BMI [95% CI 1.01 to 1.03]; p = 0.003) were patient-related factors associated with S. aureus colonization, whereas factors associated with a lower odds were older age (OR 0.99 [95% CI 0.98 to 0.99]; p < 0.001) and Black race compared with White race (OR 0.64 [95% CI 0.50 to 0.82]; p < 0.001). Among the TKA cohort, S. aureus colonization was associated with 90-day readmission (MSSA: OR 1.00 [95% CI 0.99 to 1.01]; MRSA: OR 1.01 [95% CI 1.00 to 1.01]; variable p = 0.007 by likelihood ratio test). Male sex (OR 1.19 [95% CI 1.05 to 1.34]; p = 0.006) was associated with S. aureus colonization, whereas factors associated with a lower odds of colonization were older age (OR 0.99 [95% CI 0.98 to 0.99]; p < 0.001), Veterans RAND-12 mental component score (OR 0.99 [95% CI 0.99 to 1.00]; p = 0.027), Black race compared with White race (OR 0.70 [95% CI 0.57 to 0.85]; p < 0.001), and being a former smoker (OR 0.86 [95% CI 0.75 to 0.97]; p = 0.016) or current smoker (OR 0.70 [95% CI 0.55 to 0.90]; p = 0.005) compared with those who never smoked. CONCLUSION: After controlling for the variables we explored, S. aureus colonization was associated with increased length of stay after THA and 90-day readmission after TKA, despite preoperative decolonization. Given that there is little causal biological link between colonization and these outcomes, the association is likely confounded but may be a proxy for undetermined social or biological factors, which may alert the surgeon to pay increased attention to outcomes in patients who test positive. Further study of the association of S. aureus colonization and increased length of stay after THA and readmission after TKA may be warranted to determine what the confounding variables are, which may be best accomplished using large cohorts or registry data. LEVEL OF EVIDENCE: Level III, therapeutic study.

Aspirin Is an Effective Prophylaxis for Venous Thromboembolism in Ambulatory Patients with Femoral Neck Fracture Undergoing Hip Arthroplasty.

BACKGROUND: Although aspirin has been adopted as an effective and safe prophylaxis against venous thromboembolism (VTE) by the arthroplasty community, the role of aspirin in the prevention of VTE in the setting of arthroplasty for trauma remains insufficiently known. Therefore, the present multicenter study investigated the efficacy of aspirin as VTE prophylaxis for patients with femoral neck fracture undergoing total hip arthroplasty or hemiarthroplasty. METHODS: We reviewed the medical records of 1,141 patients with femoral neck fracture who underwent total hip arthroplasty or hemiarthroplasty from 2008 to 2018 at 3 different institutions. Data on patient demographic characteristics, body mass index, history of VTE, and comorbidities were obtained from an electronic chart query and were confirmed by reviewing the medical records manually. Patients were allocated to cohorts based on the type of prophylaxis administered: aspirin (n = 454) and other anticoagulants (n = 687). Patients were then propensity score-matched on the basis of the risk score calculated using a previously validated tool and the remaining confounding variables. The primary outcome was the development of symptomatic VTE, namely deep vein thrombosis (DVT) or pulmonary embolism (PE) confirmed by appropriate imaging, within 90 days after the surgical procedure. A bivariable analysis was performed. RESULTS: The overall VTE rate was 1.98% for patients who received aspirin compared with 6.7% for patients who received other anticoagulants (p < 0.001). After propensity score matching and regression modeling, aspirin was found to be noninferior to more potent anticoagulation in preventing VTE after both total hip arthroplasty and hemiarthroplasty. CONCLUSIONS: Aspirin is an effective option for VTE prophylaxis in patients with femoral neck fracture who undergo hip arthroplasty. Based on the patient management benefits of aspirin for elective arthroplasty and the present study, we suggest its use in standard-risk ambulatory patients. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.