Safety and timing of early therapeutic anticoagulation therapy after craniotomy.

Background: To date, there are few guidelines and studies to guide the timing of initiation of therapeutic anticoagulation (AC) after craniotomy. The goal of this study was to assess the timing, safety, and outcomes of patients following the administration of therapeutic AC after craniotomy. Methods: A retrospective case-control study was performed evaluating all craniotomy patients from August 2017 to July 2021. Cases were selected if they received therapeutic AC within ten days of craniotomy. Nineteen out of 1013 craniotomy patients met the inclusion criteria. Indications for therapeutic AC were diverse, including deep venous thrombosis, pulmonary embolism, dural venous sinus thrombosis, mechanical heart valve, and left ventricular thrombus. Results: The mean and median time to therapeutic AC were 5.35 and 5 days, respectively. Three patients developed intracerebral hemorrhage (ICH) that was stable on repeat imaging and did not require any surgical intervention or result in new neurologic deficits. There was no significant association between therapeutic AC and postoperative ICH (P = 0.067). Conclusion: This study demonstrated that the initiation of therapeutic AC in postoperative craniotomy patients from postoperative days 2 to 10 did not result in any major complications. A prospective study is warranted to clarify the indications and safety of therapeutic AC after craniotomy.

Arachnoid webs with spinal cord compression: insights from three cases.

Spinal arachnoid webs are intradural bands of abnormally formed arachnoid tissue, located within the subarachnoid space and causing compression of the dorsal aspect of the spinal cord. Arachnoid webs are uncommon and can be difficult to treat. We report 3 patients presenting with a spinal arachnoid web within a 6-month period. All of them exhibited signs of thoracic myelopathy and the MRI showed the pathognomonic 'scalpel sign'. Two of the patients underwent surgery for removal of their spinal arachnoid web, whereas the third patient case is currently being managed conservatively. We also present our 2D intraoperative video for arachnoid web removal and spinal cord decompression.

Experiencing Rhythm in Dance.

In this article, two dance educators offer a definition of rhythm from both educational and performance perspectives and discuss pedagogical practices that waken students' awareness to rhythm as a lived-experience over which they have creative control. For the dancer, in the midst of the dance, rhythms are, in the words of Margaret H'Doubler, recurring patterns of measured energy. These patterns are nested in scales from the moment-to-moment shifts in muscular contraction and release to the rise and fall of dramatic tension in a performed dance. This approach to rhythm runs counter to many dance students' studio-based training in which rhythm is equated to synchronizing accents to a specific meter. The authors describe pedagogical practices in the studio that foster engagement with rhythm as lived-experience. Drawing attention to their kinesthetic experience while moving, students are encouraged to modulate levels of exertion embedded in the qualities of movement they are experiencing. As varying levels of exertion are attended to across temporal durations, students notice patterns as they emerge and recur. This attention to recurring patterns of measured exertion is, the authors claim, the lived-experience of rhythm in dance.

Giant Frontotemporal Cavernous Malformation in a 2-Month-Old Infant: A Case Report and Review of the Literature.

INTRODUCTION: Cavernous malformations in the pediatric population are exceedingly rare, especially in infants. Giant cavernous malformations (GCM) are even more rare and have a diameter >4 cm. The onset of symptoms predominantly occurs in adulthood, but the rate of hemorrhage is significantly higher in the pediatric population. Similar to non-GCM, GCM can be misidentified as tumors on imaging due to their tumefactive pattern with edema. Here, we present a rare case of a right frontotemporal GCM in a 2-month-old girl, the youngest recorded case in the existing literature. CASE PRESENTATION: A previously healthy 2-month-old girl presented to the emergency department following an increasing frequency of seizure-like activity that began 3 days prior to presentation. Magnetic resonance imaging of the brain with and without contrast characterized a large (5.8 × 4.3 × 4.2 cm) heterogeneous lesion of the right temporal lobe with diffuse scattered blood products of various ages seen throughout the lesion. She underwent a right-sided craniotomy where a gross total excision was achieved. Pathology confirmed the diagnoses of a GCM. The patient's seizures subsequently resolved, and she continues to do well postoperatively. DISCUSSION/CONCLUSION: GCM can be mistaken for tumors due to their large size, cystic nature, and surrounding edema, but a vascular lesion should always remain in the differential diagnosis before operating, even in infants. Surgery is generally recommended in patients that present with a symptomatic hemorrhage, recurrent hemorrhages, persistent seizures despite medical management, or progressively worsening neurological deficits if the GCM is in a safe location. It has been shown that 70-99% of patients undergoing surgery with successful removal of the GCM can achieve seizure freedom 2 years postoperatively. Complete surgical excision of this infant's GCM was successful in treating her neurologic symptoms; therefore, pathological confirmation of this lesion is critical and should prompt a complete surgical excision.

Management of cerebrospinal fluid leak from cervical gunshot wounds with external ventricular drainage: a small case series.

Historically, the surgical management of gunshot wounds to the spine has been controversial. Repair of a persistent cerebrospinal fluid (CSF) leak is a generally agreed upon indication. The management of such CSF leaks typically involves lumbar drainage or direct surgical repair. Here, the authors report two cases of CSF diversion with an external ventricular drain (EVD) in patients with cervical gunshot wounds. Both patients had spinal canal obliteration or physiologic myelographic block at or below the level of injury. To the best of the author's knowledge, these are the first two reports of successful EVD treatment of persistent CSF leaks related cervical gunshot wounds. The authors also propose a CSF treatment algorithm for cervical gunshot wounds that includes EVD.

Sutural loading in bone- versus dental-borne rapid palatal expansion: An ex vivo study.

OBJECTIVES: To measure and compare the success rate and strains generated during bone- (BRPE) and dental-borne rapid palatal expansion (DRPE) at the alveolar bone, zygomaticomaxillary (ZMS) and internasal (INS) sutures. Additionally, the magnitude and the pattern of midpalatal suture (MPS) separation in the 2 groups was assessed. SETTING AND SAMPLE POPULATION: The study was performed ex vivo using 28 pig heads. MATERIALS AND METHODS: Heads were dissected, and the MPS, ZMS, INS and the alveolar bone were exposed. A differential-variable-reluctance-transducer (DVRT) was installed across the MPS, and single-element strain gauges were installed at the remaining sites. Expanders were placed and activated at one turn per minute for 30 turns. Strains at the alveolar bone and the sutures and the separation of the MPS were measured. RESULTS: Successful expansion of the MPS was achieved in 69% of the BRPE subjects compared to 27% in the DRPE group. The average separation of the MPS was higher (230 ± 109 µm per turn vs. 79 ± 61 µm) and the MPS opening happened at an earlier stage of expansion in the BRPE. Higher strains at the ZMS were seen in the BRPE group, while higher strain at the alveolar bone was found in the DRPE group. CONCLUSIONS: The BRPE group demonstrated more successful and effective expansion of the MPS. Higher strain was found at the alveolar bone in the DRPE. A tendency for higher strain at the ZMS was noticed in the BRPE.

Minimally Invasive Management of Civilian Gunshot Wounds to the Lumbar Spine: A Case Series and Technical Report.

BACKGROUND: Treatment of penetrating gunshot wounds (GSW) to the spine remains controversial. The decision to operate is often based on surgeon preference and experience. We present a case series of 7 patients who underwent minimally invasive thoracolumbar/sacral decompression and bullet removal at a level 1 trauma center. OBJECTIVE: To describe the use of minimally invasive techniques to achieve decompression and bullet removal for GSW to the spine. METHODS: From 2010 to 2017, 7 patients with spinal GSW underwent minimally invasive decompression and bullet removal at an academic level 1 trauma center. RESULTS: Patient ages ranged from 20 to 55 yr (mean: 31 yr). The mechanisms of injury were GSW to the abdomen/pelvis (n = 6) and direct GSW to the spine (n = 1). Based on the neurological examination, the injuries were characterized as complete (n = 1) or incomplete (n = 6). Decompression and bullet removal were performed using a tubular retractor system. All patients with incomplete injuries who had postdischarge follow-up demonstrated some neurologic recovery. There were no postoperative wound infections, cerebrospinal fluid (CSF) fistulas, or other complications related to the procedure. CONCLUSION: Minimally invasive decompression and bullet removal is a safe technique that may help reduce the risk of postoperative infections and CSF fistulas in patients with GSW to the lumbar spine compared to the standard open technique. This approach appears to be particularly beneficial in patients with incomplete injuries and neuropathic pain refractory to medical treatment.

Moyamoya Disease in an 18-Month-Old Female Caucasian Complicated by Cerebral Hyperperfusion Syndrome Following Indirect Revascularization.

BACKGROUND Cerebral hyperperfusion syndrome is a rare complication of indirect revascularization due to moyamoya disease, but has not been reported previously in the pediatric population. We present a case of an 18-month-old girl with moyamoya disease that was treated with bilateral pial synangiosis and had complications consistent with cerebral hyperperfusion syndrome. This case report discusses the pathophysiological mechanisms involved in cerebral hyperperfusion in moyamoya syndrome. CASE REPORT An 18-month-old female Caucasian presented with seizures and weakness of the left side. Angiography confirmed bilateral cerebral moyamoya disease that was worse on the right side. Indirect revascularization with pial synangiosis was first performed on the right side to allow for healing. Five months later, pial synangiosis was then performed on the left side. Postoperatively, the patient experienced increased intracranial pressure (ICP), suggesting cerebral hyperperfusion syndrome. She was treated with a repeat lumbar puncture, a lumbar drain, and a lumbar shunt. CONCLUSIONS This report demonstrates a case of cerebral hyperperfusion syndrome as a complication of moyamoya disease in a pediatric patient. Although the patient progressed well after placement of a lumbar shunt, this case demonstrates the occurrence of cerebral hyperperfusion syndrome as a complication of revascularization in pediatric patients and highlights the need for further research in this area.

A Case of Non-Islet Cell Tumor Hypoglycemia (NICTH) Associated with Gastrointestinal Stromal Tumor (GIST).

BACKGROUND Non-islet cell tumor hypoglycemia (NICTH) is a newly recognized, but uncommon, paraneoplastic syndrome that is associated with tumors of mesenchymal origin. We report a case of NICTH associated with a gastrointestinal stromal tumor (GIST). CASE REPORT A 60-year-old man presented to the emergency department of our hospital after being found unconscious in his home. His serum blood glucose on hospital admission was 40 mg/dL. He reported a three-month history of diffuse abdominal pain, fatigue, and blurred vision. Laboratory medicine investigations showed reduced levels of insulin, C-peptide, insulin-like growth factor binding protein (IGFBP)-3, and insulin-like growth factor (IGF)-1, but his IGFBP-2 was increased. Computed tomography (CT) scan of the chest and abdomen showed an abdominal mass that involved the small bowel, mesentery, and omentum, with lesions in the right lung and the left rib. Histopathology of a CT-guided biopsy of the abdominal mass showed a low-grade sarcomatous spindle cell neoplasm that was positive for CD117 using immunohistochemistry and with an exon 11 c-KIT mutation. These findings were consistent with a diagnosis of GIST and treatment with imatinib commenced. CONCLUSIONS This case report has shown that hypoglycemia in the setting of low levels of insulin, C-peptide, IGF-1, and IGFBP-3 is suggestive of a diagnosis of NICTH, which should be investigated for an underlying source, which in this case, was confirmed to be a malignant GIST.

Therapeutic options in the management of obesity.

In New Zealand 28.4% of adults now classify as obese, whilst a total of 63.8% are overweight or obese (BMI >25 kg/m²). This presents an ever increasing social and economic burden to individuals, families and the healthcare system. Obesity is a major risk factor for cancer, cardiovascular, metabolic, and respiratory disorders. Preventing obesity is the optimal long-term population strategy and must be a government priority. There are many approaches which could be taken to facilitate this, however it is important not to forget those who are currently overweight or obese. This review addresses the current therapeutic options in the treatment of obesity, focusing on lifestyle changes, medications, and surgery in New Zealand. It also presents a suggested algorithm for the clinician assessing and managing obese patients in New Zealand.

Effect of alpha1-adrenoceptor antagonist exposure on prostate cancer incidence: an observational cohort study.

PURPOSE: The quinazoline based alpha1-adrenoceptor antagonists doxazosin and terazosin suppress prostate tumor growth via the induction of apoptosis and decrease in tissue vascularity. To assess the effect of alpha1-blocker exposure on the incidence of prostate cancer we performed an exploratory, observational cohort study. MATERIALS AND METHODS: The medical records of all male patients enrolled at Lexington Veterans Affairs Medical Center were searched to identify men treated with quinazoline based alpha1-adrenoreceptor antagonists between January 1, 1998 and December 31, 2002 for hypertension and/or benign prostatic enlargement. Medical records were subsequently linked to the Markey Cancer Center Kentucky Cancer Registry, a statewide population based central cancer registry that is part of the National Cancer Institute Surveillance, Epidemiology and End Results Program, to identify all incident prostate cancer cases diagnosed. All newly diagnosed prostate cancer cases unexposed to alpha1-adrenoreceptor antagonists in the total male Veterans Affairs population during this period were also identified from the Kentucky Cancer Registry database. Measures of disease incidence, relative risk and attributable risk were calculated to compare the risk of prostate cancer in alpha1-blocker exposed vs unexposed men. Kaplan-Meier curves and Cox regression models were used to compare overall survival between alpha1-blocker exposed and unexposed prostate cancer cases. RESULTS: Our analysis revealed a cumulative incidence of 1.65% in alpha1-blocker exposed men compared to 2.41% in the unexposed group. These data yielded an unadjusted RR of 0.683 (95% CI 0.532, 0.876) and a risk difference of -0.0076, indicating that 7.6 fewer prostate cancer cases developed per 1,000 exposed men. Thus, exposure to quinazoline alpha1-blockers may have prevented 32 prostate cancer cases among the 4,070 treated men during the study period. Therefore, men exposed to quinazoline alpha1-adrenoceptor antagonists were at 1.46 times lower RR and 31.7% lower attributable risk for prostate cancer than unexposed men. There was no association between alpha1-adrenoceptor antagonist exposure and overall survival. CONCLUSIONS: These data suggest that exposure to quinazoline based alpha1-adrenoceptor antagonists significantly decreases the incidence of prostate cancer. This evidence suggests that the apoptotic and anti-angiogenic effects of these drugs may prevent the development of prostate cancer.

A foxy intoxication.

Foxy is the colloquial name for the hallucinogen 5-ethoxy-diisopropyltryptamine (5-MeO-DIPT). A non-fatality involving a 23-year-old Caucasian man who ingested a capsule containing 5-MeO-DIPT is described. He presented to the Emergency Department, not with visual nor auditory hallucinations but with sensory hallucinations, that of formication and paranoia. He was observed and given supportive care for 4 h, then discharged without any known sequelae. Blood and urine were collected for laboratory analyses. Foxy and its metabolites were identified in urine by gas chromatography-mass spectrometry. The concentrations of 5-MeO-DIPT in the serum and urine were 0.14 and 1.6 microg/mL, respectively. The drug undergoes oxidative deamination to form 5-methoxy-indole acetic acid. The urinary concentration of this metabolite was 0.17 microg/mL. Also, the urine contained three other related compounds. Two of them have been described in a previous case of 5-MeO-DIPT ingestion as 5-methoxy-isopropyltryptamine (5-MeO-IPT) and 5-methoxy-diisopropyltryptamine-N'-oxide (5-MeO-DIPT-N'-oxide). The third compound was substantially present in the urine and was tentatively identified as 5-hydroxy-diisopropyltryptamine (5-OH-DIPT). Only the parent drug, 5-MeO-DIPT was detected in the serum sample.