Median Arcuate Ligament Syndrome in 17-year-old Male with Abdominal Pain: Case Report.

Introduction: Median arcuate ligament syndrome (MALS) is an uncommon cause of chronic abdominal pain resulting from the compression of the celiac artery. It shares symptoms with chronic functional abdominal pain, a more common cause of pediatric chronic abdominal pain. Typically found in middle-aged females, MALS is a diagnosis of exclusion. Case Report: A 17-year-old male who presented to the emergency department with periumbilical pain for two months was subsequently diagnosed with MALS through computed tomography angiography. Further vascular and gastroenterology evaluations confirmed the diagnosis, ruling out other common causes of chronic abdominal pain. The patient received non-operative treatment in the form of endoscopic ultrasound celiac plexus block, with the possibility of surgical management if necessary. Conclusion: Median arcuate ligament syndrome is an uncommon cause of chronic abdominal pain that is difficult to differentiate from other causes, especially in pediatric patients. It should be considered in the patient whose previous workup was not conclusive and symptom management had failed. Management is multidisciplinary with non-operative management preferred initially. If there is no improvement, surgical management should be considered.

The Clinical Cell-Cycle Risk (CCR) Score Is Associated With Metastasis After Radiation Therapy and Provides Guidance on When to Forgo Combined Androgen Deprivation Therapy With Dose-Escalated Radiation.

PURPOSE: The clinical cell-cycle risk (CCR) score, which combines the University of California, San Francisco's Cancer of the Prostate Risk Assessment (CAPRA) and the cell cycle progression (CCP) molecular score, has been validated to be prognostic of disease progression for men with prostate cancer. This study evaluated the ability of the CCR score to prognosticate the risk of metastasis in men receiving dose-escalated radiation therapy (RT) with or without androgen deprivation therapy (ADT). METHODS AND MATERIALS: This retrospective, multi-institutional cohort study included men with localized National Comprehensive Cancer Network (NCCN) intermediate-, high-, and very high-risk prostate cancer (N = 741). Patients were treated with dose-escalated RT with or without ADT. The primary outcome was time to metastasis. RESULTS: The CCR score prognosticated metastasis with a hazard ratio (HR) per unit score of 2.22 (95% confidence interval [CI], 1.71-2.89; P < .001). The CCR score better prognosticated metastasis than NCCN risk group (CCR, P < .001; NCCN, P = .46), CAPRA score (CCR, P = .002; CAPRA, P = .59), or CCP score (CCR, P < .001; CCP, P = .59) alone. In bivariable analyses, CCR score remained highly prognostic when accounting for ADT versus no ADT (HR, 2.18; 95% CI, 1.61-2.96; P < .001), ADT duration as a continuous variable (HR, 2.11; 95% CI, 1.59-2.79; P < .001), or ADT given at or below the recommended duration for each NCCN risk group (HR, 2.19; 95% CI, 1.69-2.86; P < .001). Men with CCR scores below or above the multimodality threshold (CCR score, 2.112) had a 10-year risk of metastasis of 3.7% and 21.24%, respectively. Men with below-threshold scores receiving RT alone had a 10-year risk of metastasis of 3.7%, and for men receiving RT plus ADT, the 10-year risk of metastasis was also 3.7%. CONCLUSIONS: The CCR score accurately and precisely prognosticates metastasis and adds clinically actionable information relative to guideline-recommended therapies based on NCCN risk in men undergoing dose-escalated RT with or without ADT. For men with scores below the multimodality threshold, adding ADT may not significantly reduce their 10-year risk of metastasis.

Dedifferentiation alters chondrocyte nuclear mechanics during in vitro culture and expansion.

The biophysical features of a cell can provide global insights into diverse molecular changes, especially in processes like the dedifferentiation of chondrocytes. Key biophysical markers of chondrocyte dedifferentiation include flattened cellular morphology and increased stress-fiber formation. During cartilage regeneration procedures, dedifferentiation of chondrocytes during in vitro expansion presents a critical limitation to the successful repair of cartilage tissue. Our study investigates how biophysical changes of chondrocytes during dedifferentiation influence the nuclear mechanics and gene expression of structural proteins located at the nuclear envelope. Through an experimental model of cell stretching and a detailed spatial intranuclear strain quantification, we identified that strain is amplified and the distribution of strain within the chromatin is altered under tensile loading in the dedifferentiated state. Further, using a confocal microscopy image-based finite element model and simulation of cell stretching, we found that the cell shape is the primary determinant of the strain amplification inside the chondrocyte nucleus in the dedifferentiated state. Additionally, we found that nuclear envelope proteins have lower gene expression in the dedifferentiated state. This study highlights the role of cell shape in nuclear mechanics and lays the groundwork to design biophysical strategies for the maintenance and enhancement of the chondrocyte phenotype during cell expansion with a goal of successful cartilage tissue engineering.

Approach to nephrostomy tubes in the emergency department.

BACKGROUND: Nephrostomy tubes are commonly placed for urinary obstruction, urinary diversion, or future endourologic procedures. While the technical success of nephrostomy tube placement is high, nephrostomy tube complications may occur. OBJECTIVE OF REVIEW: Limited literature exists regarding the complication of nephrostomy tubes and their approach in the emergency department. This review summarizes the existing literature and provides a framework for emergency providers regarding the evaluation and management of nephrostomy tube complications. DISCUSSION: Nephrostomy tube failure, caused by kinking, dislodgment, or migration can manifest with obstructive signs and symptoms. In well appearing patients, asymptomatic bacteriuria is common and should not be treated. However, in the presence of infectious symptoms, patients should be treated similarly to complicated cystitis or pyelonephritis. While gross hematuria is common following catheter placement, prolonged hematuria, or the return of hematuria after previous resolution should trigger investigation for hematoma formation or a delayed presentation of an intraoperative vascular injury. Finally, clinicians should obtain laboratory testing, advanced imaging, and specialty consultation if serious complications are suspected. CONCLUSION: This narrative review highlights general nephrostomy tube care, minor complications, and troubleshooting in the emergency department. The majority of these minor complications can be managed at the bedside without specialty consultation. However, in patients with more serious complications including dislodgement, obstruction, infection, bleeding, and pleural injury, laboratory assessment and advanced imaging to include ultrasound and computed tomography with specialty consultation are essential in the patient's evaluation and management, particularly in cases of immune compromise and worsening renal function.

Evolving understanding and categorization of prostate cancer: preventing progression to metastatic castration-resistant prostate cancer: RADAR IV.

INTRODUCTION To interpret data and update the traditional categorization of prostate cancer in order to help treating clinicians make more informed decisions. These updates include guidance regarding how to best use next generation imaging (NGI) with the caveat that the new imaging technologies are still a work in progress. MATERIALS AND METHODS: Literature review. RESULTS: Critical goals in prostate cancer management include preventing or delaying emergence of distant metastases and progression to castration-resistant disease. Pathways for progression to metastatic castration-resistant prostate cancer (mCRPC) involve transitional states: nonmetastatic castration-resistant prostate cancer (nmCRPC), metastatic hormone-sensitive prostate cancer (mHSPC), and oligometastatic disease. Determination of clinical state depends in part on available imaging modalities. Currently, fluciclovine and gallium-68 (68Ga) prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) are the NGI approaches with the most favorable combination of availability, specificity, and sensitivity. PET imaging can be used to help guide treatment selection in most patients. NGI can help determine patients who are candidates for new treatments, most notably (next-generation androgen antagonists, eg, apalutamide, enzalutamide, darolutamide), that can delay progression to advanced disease. CONCLUSIONS: It is important to achieve a consensus on new and more easily understood terminology to clearly and effectively describe prostate cancer and its progression to health care professionals and patients. It is also important that description of disease states make clear the need to initiate appropriate treatment. This may be particularly important for disease in transition to mCRPC.

ST-Segment Elevation in the Setting of Diabetic Ketoacidosis: Is It Acute Coronary Syndrome?

Diabetic ketoacidosis (DKA) with resulting hyperkalemia can lead to ST-segment elevations on electrocardiogram (ECG). Previous publications theorize that significant improvements in patient potassium levels lead to the resolution of this rare phenomenon, also known as "pseudo-infarct" pattern. The authors provide a unique case along with a literature review of DKA-associated ST-segment elevations. This specific case distinctively demonstrates the resolution of the pseudo-infarct pattern in the setting of minor improvements in serum potassium and continued acidosis.

Optimizing the role of androgen deprivation therapy in advanced prostate cancer: Challenges beyond the guidelines.

BACKGROUND: For specific clinical indications, androgen deprivation therapy (ADT) will induce disease prostate cancer (PC) regression, relieve symptoms and prolong survival; however, ADT has a well-described range of side effects, which may have a detrimental effect on the patient's quality of life, necessitating additional interventions or changes in PC treatment. The risk-benefit analysis for initiating ADT in PC patients throughout the PC disease continuum warrants review. METHODS: A 14-member panel comprised of urologic and medical oncologists were chosen for an expert review panel, to provide guidance on a more judicious use of ADT in advanced PC patients. Panel members were chosen based upon their academic and community experience and expertise in the management of PC patients. Four academic members of the panel served as group leaders; the remaining eight panel members were from Large Urology Group Practice Association practices with proven experience in leading their advanced PC clinics. The panel members were assigned to four separate working groups, and were tasked with addressing the role of ADT in specific PC settings. RESULTS: This article describes the practical recommendations of an expert panel for the use of ADT throughout the PC disease continuum, as well as an algorithm summarizing the key recommendations. The target for this publication is all providers (urologists, medical oncologists, radiation oncologists, or advanced practice providers) who evaluate and manage advanced PC patients, regardless of their practice setting. CONCLUSION: The panel has provided recommendations for monitoring PC patients while on ADT, recognizing that PC patients will progress despite testosterone suppression and, therefore, early identification of conversion from castrate-sensitive to castration resistance is critical. Also, the requirement to both identify and mitigate side effects of ADT as well as the importance of quality of life maintenance are essential to the optimization of patient care, especially as more combinatorial therapeutic strategies with ADT continue to emerge.

Deformation Microscopy for Dynamic Intracellular and Intranuclear Mapping of Mechanics with High Spatiotemporal Resolution.

Structural heterogeneity is a hallmark of living cells that drives local mechanical properties and dynamic cellular responses. However, the robust quantification of intracellular mechanics is lacking from conventional methods. Here, we describe the development of deformation microscopy, which leverages conventional imaging and an automated hyperelastic warping algorithm to investigate strain history, deformation dynamics, and changes in structural heterogeneity within the interior of cells and cell nuclei. Using deformation microscopy, we found that partial or complete disruption of LINC complexes in cardiomyocytes in vitro and lamin A/C deficiency in myocytes in vivo abrogate dominant tensile loading in the nuclear interior. We also found that cells cultured on stiff substrates or in hyperosmotic conditions displayed abnormal strain burden and asymmetries at interchromatin regions, which are associated with active transcription. Deformation microscopy represents a foundational approach toward intracellular elastography, with the potential utility to provide mechanistic and quantitative insights in diverse mechanobiological applications.

Necrotic Fibroid Mimicking Ovarian Torsion in a Second Trimester of Pregnancy.

Uterine fibroids are incredibly common, benign smooth muscle tumors which range in severity of symptoms from asymptomatic to debilitating. While pain is frequently a symptom, degeneration and necrosis of uterine fibroids can rarely present as acute abdomen. The authors present the case of a pregnant female at 19 weeks' gestation, whose clinical and radiographic presentation mimicked that of ovarian torsion, ultimately requiring exploratory laparoscopy for definitive diagnosis.

Rattlesnake Envenomation in the Third Trimester of Pregnancy.

BACKGROUND: Snakebites in pregnancy can be life-threatening to both the mother and fetus as a result of inflammatory and toxic properties of the venom. Prompt medical treatment is critical to prevent adverse consequences. CASE: A 26-year-old woman at 37 6/7 weeks of gestation was bitten by a rattlesnake on the right middle finger, resulting in severe pain radiating up to the upper arm and swelling involving the entire hand. A total of 18 vials of crotalidae polyvalent immune fab was administered over 11 hours. Three days after the incident, the patient delivered a healthy neonate vaginally and without complications. Both mother and newborn were well at 1-month follow-up. CONCLUSION: Our case supports managing snakebites in pregnancy similar to managing cases in nonpregnant individuals, including using crotalidae polyvalent immune fab antivenom.

Multiorgan system structural malformations associated with Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS) type 2: avoiding pitfalls in diagnosis, counseling and treatment.

An 18-year-old virginal woman was referred to the reproductive endocrinology clinic with primary amenorrhoea and secondary sexual development in the absence of pelvic pain. Additionally, she had significant congenital sensorineural hearing loss, autism, bipolar disorder and class III obesity. On physical examination, secondary sexual development was confirmed (Tanner 5 breasts and Tanner 4 pubic hair). She refused further pelvic examination following prior attempts by the referring physicians. Serum leutinizing hormone (LH), follicle sitmulating hormone (FSH). prolactin, estradiol and total testosterone values were within normal limits. Karyotype was 46,XX. MRI demonstrated complete uterine agenesis, short vagina, sacral dysgenesis with complete absence of the coccyx and a horseshoe kidney. Diagnosis of Mayer-Rokitansky-Küster-Hauser Syndrome type 2 was established based on clinical, laboratory and MRI findings. The patient and family were counselled regarding the disease process, techniques for vaginal elongation, sexual activity and future reproductive options.

Use of a 17-Gene Prognostic Assay in Contemporary Urologic Practice: Results of an Interim Analysis in an Observational Cohort.

OBJECTIVE: To study the impact of genomic testing in shared decision making for men with clinically low-risk prostate cancer (PCa). MATERIALS AND METHODS: Patients with clinically low-risk PCa were enrolled in a prospective, multi-institutional study of a validated 17-gene tissue-based reverse transcription polymerase chain reaction assay (Genomic Prostate Score [GPS]). In this paper we report on outcomes in the first 297 patients enrolled in the study with valid 17-gene assay results and decision-change data. The primary end points were shared decision on initial management and persistence on active surveillance (AS) at 1 year post diagnosis. AS utilization and persistence were compared with similar end points in a group of patients who did not have genomic testing (baseline cohort). Secondary end points included perceived utility of the assay and patient decisional conflict before and after testing. RESULTS: One-year results were available on 258 patients. Shift between initial recommendation and shared decision occurred in 23% of patients. Utilization of AS was higher in the GPS-tested cohort than in the untested baseline cohort (62% vs 40%). The proportion of men who selected and persisted on AS at 1 year was 55% and 34% in the GPS and baseline cohorts, respectively. Physicians reported that GPS was useful in 90% of cases. Mean decisional conflict scores declined in patients after GPS testing. CONCLUSION: Patients who received GPS testing were more likely to select and persist on AS for initial management compared with a matched baseline group. These data indicate that GPS help guide shared decisions in clinically low-risk PCa.

The LUGPA Alternative Payment Model for Initial Therapy of Newly Diagnosed Patients With Organ-confined Prostate Cancer: Rationale and Development.

Over the past several decades, rapid expansion in healthcare expenditures has exposed the utilization incentives inherent in fee-for-service payment models. The passage of Medicare Access and CHIP Reauthorization Act of 2015 heralded a transition toward value-based care, creating incentives for practitioners to accept bidirectional risk linked to outcome and utilization metrics. At present, the limited availability of these vehicles excludes all but a handful of providers from participation in alternative payment models (APMs). The LUGPA APM supports the goals of the triple aim in improving the patient experience, enhancing population health and reducing expenditures. By requiring utilization of certified electronic health record technologies, tying payment to quality metrics, and requiring practices to bear more than nominal risk, the LUGPA APM qualifies as an advanced APM, thereby easing the reporting burden and creating opportunities for participating practices.

Reciprocal Risk of Acute Kidney Injury and Acute Respiratory Distress Syndrome in Critically Ill Burn Patients.

OBJECTIVE: To evaluate the association between acute respiratory distress syndrome and acute kidney injury with respect to their contributions to mortality in critically ill patients. DESIGN: Retrospective analysis of consecutive adult burn patients requiring mechanical ventilation. SETTING: A 16-bed burn ICU at tertiary military teaching hospital. PATIENTS: Adult patients more than 18 years old requiring mechanical ventilation during their initial admission to our burn ICU from January 1, 2003, to December 31, 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total 830 patients were included, of whom 48.2% had acute kidney injury (n = 400). These patients had a 73% increased risk of developing acute respiratory distress syndrome after controlling for age, gender, total body surface area burned, and inhalation injury (hazard ratio, 1.73; 95% CI, 1.18-2.54; p = 0.005). In a reciprocal multivariate analysis, acute respiratory distress syndrome (n = 299; 36%) demonstrated a strong trend toward developing acute kidney injury (hazard ratio, 1.39; 95% CI, 0.99-1.95; p = 0.05). There was a 24% overall in-hospital mortality (n = 198). After adjusting for the aforementioned confounders, both acute kidney injury (hazard ratio, 3.73; 95% CI, 2.39-5.82; p < 0.001) and acute respiratory distress syndrome (hazard ratio, 2.16; 95% CI, 1.58-2.94; p < 0.001) significantly contributed to mortality. Age, total body surface area burned, and inhalation injury were also significantly associated with increased mortality. CONCLUSIONS: Acute kidney injury increases the risk of acute respiratory distress syndrome in mechanically ventilated burn patients, whereas acute respiratory distress syndrome similarly demonstrates a strong trend toward the development of acute kidney injury. Acute kidney injury and acute respiratory distress syndrome are both independent risks for subsequent death. Future research should look at this interplay for possible early interventions.

Acute Respiratory Distress Syndrome in Burn Patients: A Comparison of the Berlin and American-European Definitions.

The purpose of this study was to compare the Berlin definition to the American-European Consensus Conference (AECC) definition in determining the prevalence of acute respiratory distress syndrome (ARDS) and associated mortality in the critically ill burn population. Consecutive patients admitted to our institution with burn injury that required mechanical ventilation for more than 24 hours were included for analysis. Included patients (N = 891) were classified by both definitions. The median age, % TBSA burn, and injury severity score (interquartile ranges) were 35 (24-51), 25 (11-45), and 18 (9-26), respectively. Inhalation injury was present in 35.5%. The prevalence of ARDS was 34% using the Berlin definition and 30.5% using the AECC definition (combined acute lung injury and ARDS), with associated mortality rates of 40.9 and 42.9%, respectively. Under the Berlin definition, mortality rose with increased ARDS severity (14.6% no ARDS; 16.7% mild; 44% moderate; and 59.7% severe, P < 0.001). By contrast, under the AECC definition increased mortality was seen only for ARDS category (14.7% no ARDS; 15.1% acute lung injury; and 46.0% ARDS, P < 0.001). The mortality of the 22 subjects meeting the AECC, but not the Berlin definition was not different from patients without ARDS (P = .91). The Berlin definition better stratifies ARDS in terms of severity and correctly excludes those with minimal disease previously captured by the AECC.

Pulmonary Microscopic Polyangiitis Presenting as Acute Respiratory Failure from Diffuse Alveolar Hemorrhage.

Microscopic polyangiitis and granulomatosis with polyangiitis are rare anti-neutrophilic cytoplasmic antibody-associated systemic vasculitides that predominantly affect small to medium sized vessels of the lungs and kidneys. These syndromes are largely confined to older adults and often present sub-acutely following weeks to months of nonspecific prodromal symptoms. While both diseases often manifest within multiple organ systems concurrently, the disease spectrum of microscopic polyangiitis almost always includes the kidneys, while granulomatosis with polyangiitis is most commonly associated with pulmonary disease. We present two cases of rapid onset respiratory failure secondary to diffuse alveolar hemorrhage in young active duty military personnel. After serological testing and surgical lung biopsy, both patients were diagnosed with microscopic polyangiitis with isolated pulmonary involvement.

A comparison of acute respiratory distress syndrome outcomes between military and civilian burn patients.

BACKGROUND: The objective of this report was to compare the prevalence of acute respiratory distress syndrome (ARDS) and associated mortality between military service members with burns sustained during or in support of combat operations and civilian burn patients treated at a single burn center. METHODS: Demographic and physiologic data were collected retrospectively on mechanically ventilated military and civilian patients admitted to our burn intensive care unit between January 2003 and December 2011. Patients with ARDS were identified and categorized as mild, moderate, or severe using the Berlin criteria. Demographics and clinical outcomes were compared. After initial comparison, propensity matching was performed and mortality compared. RESULTS: A total of 891 burn patients required mechanical ventilation during the study period; 291 military and 600 civilian. The prevalence of ARDS was 34% (n=304) for the entire cohort, 33% (n=96) for military, and 35% (n=208) for civilians (p=0.55). For the entire cohort, despite more severe injury burden, military patients had a significantly lower overall mortality (17% vs. 28%; p=0.0002) as well as ARDS mortality (33 vs. 48%, p=0.02) when compared to civilians. This difference was not significant after propensity matching based on age. CONCLUSION: In a retrospective cohort study, burned military patients on mechanical ventilation had a significantly lower overall and ARDS mortality despite larger burns and more severe injury when compared to civilian burn patients. This difference appears to be largely because of age.

Acute respiratory distress syndrome in wartime military burns: application of the Berlin criteria.

BACKGROUND: Acute respiratory distress syndrome (ARDS) prevalence and related outcomes in burned military casualties from Iraq and Afghanistan have not been described previously. The objective of this article was to report ARDS prevalence and its associated in-hospital mortality in military burn patients. METHODS: Demographic and physiologic data were collected retrospectively on mechanically ventilated military casualties admitted to our burn intensive care unit from January 2003 to December 2011. Patients with ARDS were identified in accordance with the new Berlin definition of ARDS. Subjects were categorized as having mild, moderate, or severe ARDS. Multivariate logistic regression identified independent risk factors for developing moderate-to-severe ARDS. The main outcome measure was the prevalence of ARDS in a cohort of patients burned as a result of recent combat operations. RESULTS: A total of 876 burned military casualties presented during the study period, of whom 291 (33.2%) required mechanical ventilation. Prevalence of ARDS in this cohort was 32.6%, with a crude overall mortality of 16.5%. Mortality increased significantly with ARDS severity: mild (11.1%), moderate (36.1%), and severe (43.8%) compared with no ARDS (8.7%) (p < 0.001). Predictors for the development of moderate or severe ARDS were inhalation injury (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.01-3.54; p = 0.046), Injury Severity Score (ISS) (OR, 1.04; 95% CI, 1.01-1.07; p = 0.0021), pneumonia (OR, 198; 95% CI, 1.07-3.66; p = 0.03), and transfusion of fresh frozen plasma (OR, 1.32; 95% CI, 1.01-1.72; p = 0.04). Size of burn was associated with moderate or severe ARDS by univariate analysis but was not an independent predictor of ARDS by multivariate logistic regression (p > 0.05). Age, size of burn, and moderate or severe ARDS were independent predictors of mortality. CONCLUSION: In this cohort of military casualties with thermal injuries, nearly a third required mechanical ventilation; of those, nearly one third developed ARDS, and nearly one third of patients with ARDS did not survive. Moderate and severe ARDS increased the odds of death by more than fourfold and ninefold, respectively. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.