Diaphragma sellae sinking can predict the onset of hyponatremia after transsphenoidal surgery for pituitary adenomas.

PURPOSE: Sinking of the diaphragma sellae (DS) may stretch the pituitary stalk, which in turn impairs neurohypophyseal function; thus, it may play a role in the development of postoperative hyponatremia. We aimed to assess the factors influencing the development of hyponatremia after transsphenoidal surgery (TSS) for pituitary adenomas and analyze the effect of DS sinking on hyponatremia. METHODS: After applying the inclusion and exclusion criteria, we retrospectively analyzed the clinical data of patients with pituitary adenoma who underwent TSS. The pituitary gland was scanned using a 3.0-T magnetic resonance imaging, and sagittal and coronal images were acquired. We evaluated the following: preoperative and postoperative hypothalamus‒pituitary‒thyroid axis function, hypothalamus‒pituitary‒adrenal axis function, intra-operative cerebrospinal fluid leaks, diabetes insipidus, hyponatremia, time from the day of surgery to the day of discharge, and time of hyponatremia onset. RESULTS: Of the 460 patients who had microscopic TSS for pituitary adenoma, 83 experienced postoperative hyponatremia. Hyponatremia occurred approximately 5.25 days postoperatively and persisted for 5.54 days. The lowest average blood sodium level was 123.9 mEq/L, which occurred at 7.49 days after surgery. Logistic regression analysis showed that the risk of hyponatremia was greater for patients with a significant DS sinking depth, a large pituitary stalk deviation angle difference, and a longer postoperative "measurable pituitary stalk". The difference in blood sodium levels between pre-TSS and 2 days post-TSS was also an independent predictor of postoperative hyponatremia onset. CONCLUSION: DS sinking plays an important role in predicting hyponatremia onset after TSS for pituitary adenomas.

The Correlative Factors and Probable Mechanism of Epidural Fluid Collection After Cranioplasty.

OBJECTIVE: Epidural fluid collection (EFC) is one of the postoperative complications of cranioplasty and is easily ignored. Not only the predictive factors of EFC formation are unknown, the pathologic mechanisms are also unknown. We determined to analyze the predictive factors and the mechanism of EFC formation. METHODS: A total of 340 patients underwent cranioplasty were retrospectively analyzed in this study. A series of factors were compared in the EFC and none-EFC groups and farther compared in the progress epidural fluid collection (PEFC) and none-PEFC subgroups to determine the predictive factors. The t test, χ test, and logistic regression analysis were used in statistical analysis. RESULTS: The rate of EFC formation was 34.41%, and the size of skull defect, preoperative volume of collapse, intraoperative dura suspending, a pre- or intraoperative ventriculoperitoneal shunt (V-P shunt), and an postoperative air bubble in epidural space were predictive factors for EFC formation. Furthermore, the incidence of PEFC was 10.29%, the size of skull defects and intraoperative dura suspending were predictive factors for PEFC formation. The protein ratio and lactate dehydrogenase (LDH) ratio of effusion to serum were >0.5 and 0.6, respectively. There was no adverse prognosis. CONCLUSIONS: Although EFC can be treated with conservative therapy, we need to emphasize EFC incidence and development. As neurosurgeons, it is necessary to analyze the preoperative predictive factors of EFC, pay attention to the intraoperative details such as dura suspending to prevent PEFC formation, and the early intervention should be performed in the postoperative.

Assessment of cerebrovascular alterations induced by inflammatory response and oxidative-nitrative stress after traumatic intracranial hypertension and a potential mitigation strategy.

The rapid perfusion of cerebral arteries leads to a significant increase in intracranial blood volume, exposing patients with traumatic brain injury to the risk of diffuse brain swelling or malignant brain herniation during decompressive craniectomy. The microcirculation and venous system are also involved in this process, but the precise mechanisms remain unclear. A physiological model of extremely high intracranial pressure was created in rats. This development triggered the TNF-α/NF-κB/iNOS axis in microglia, and released many inflammatory factors and reactive oxygen species/reactive nitrogen species, generating an excessive amount of peroxynitrite. Subsequently, the capillary wall cells especially pericytes exhibited severe degeneration and injury, the blood-brain barrier was disrupted, and a large number of blood cells were deposited within the microcirculation, resulting in a significant delay in the recovery of the microcirculation and venous blood flow compared to arterial flow, and this still persisted after decompressive craniectomy. Infliximab is a monoclonal antibody bound to TNF-α that effectively reduces the activity of TNF-α/NF-κB/iNOS axis. Treatment with Infliximab resulted in downregulation of inflammatory and oxidative-nitrative stress related factors, attenuation of capillary wall cells injury, and relative reduction of capillary hemostasis. These improved the delay in recovery of microcirculation and venous blood flow.

Acute subdural haematoma exacerbates cerebral blood flow disorder and promotes the development of intraoperative brain bulge in patients with severe traumatic brain injury.

BACKGROUND: Decompressive craniectomy (DC) is a routine procedure used for the treatment of severe traumatic brain injury (TBI) with concomitant acute subdural haematoma (SDH). However, certain patients are prone to developing malignant brain bulge during DC, which prolongs the operative time and worsens patient outcomes. Previous studies have shown that malignant intraoperative brain bulge (IOBB) may be associated with excessive arterial hyperaemia caused by cerebrovascular system disorders. Through a clinical retrospective analysis and prospective observations, we found that the cerebral blood flow of patients who possessed risk factors manifested high resistance and low flow velocity, which severely affected brain tissue perfusion and resulted in the occurrence of malignant IOBB. In the current literature, rat models of severe brain injury-associated brain bulge have rarely been reported. METHODS: To gain an in-depth understanding of cerebrovascular changes and the cascade of responses related to brain bulge, we introduced acute SDH into the Marmarou model for the preparation of a rat model of high intracranial pressure (ICP) to simulate the pathological conditions experienced by patients with severe brain injury. RESULTS: With the introduction of a 400-µL haematoma, significant dynamic changes occurred in ICP, mean arterial pressure, and relative blood perfusion rate of the cerebral cortical vessels. ICP increased to 56.9 ± 2.3 mmHg, mean arterial pressure showed reactive decrease, and the blood flow of cerebral cortical arteries and veins on the non-SDH-affected side decreased to < 10%. These changes could not fully recover even after DC. This resulted in generalised damage to the neurovascular unit and a lag effect to the venous blood reflux, which triggered malignant IOBB formation during DC. CONCLUSION: An excessive increase in ICP causes cerebrovascular dysfunction and brings about a cascade of damage to brain tissue, which forms the basis for the development of diffuse brain swelling. The subsequent heterogeneous responses of the cerebral arteries and veins during craniotomy may be the main cause of primary IOBB. Clinicians should pay particular attention to the redistribution of CBF to various vessels when performing DC in patients with severe TBI.

Diabetes Is Negatively Associated With Meeting Physical Activity Time-Intensity Guidelines in Patients With Claudication.

PURPOSES: We determined the percentage of patients with peripheral artery disease (PAD) and claudication who meet the 2018 physical activity (PA) time-intensity guidelines, and we identified the clinical characteristics associated with the status of meeting the guidelines. METHODS: Five hundred seventy-two patients were assessed on their daily ambulatory activity for 1 wk with a step activity monitor, and were evaluated on whether or not they achieved 150 min/wk of moderate-intensity PA. RESULTS: Thirty-one percent (n = 175) of the patients with PAD met the PA time-intensity guidelines and 69% (n = 397) did not. In a final multivariable logistic regression model identifying the independent predictors of meeting the PA time-intensity guidelines from clinical characteristics, diabetes was the only significant variable entered (OR = 0.310: 95% CI, 0.175-0.538; P < .001) and was associated with a 69% lower chance of meeting the guidelines. Patients with diabetes spent less daily time in moderate-intensity ambulatory PA than patients without diabetes (15 ± 13 vs 23 ± 20 min/d; P < .001). CONCLUSIONS: Thirty-one percent of patients with PAD and claudication met the PA time-intensity guidelines. Furthermore, patients with diabetes were least likely to meet the PA time-intensity guidelines, as they had a 69% lower chance than patients without diabetes. The clinical significance is that PAD patients who have diabetes are particularly susceptible to being physically sedentary, and are therefore prime patients who should be encouraged to increase their daily PA.

Stereoscopic virtual reality models for planning tumor resection in the sellar region.

BACKGROUND: It is difficult for neurosurgeons to perceive the complex three-dimensional anatomical relationships in the sellar region. METHODS: To investigate the value of using a virtual reality system for planning resection of sellar region tumors. The study included 60 patients with sellar tumors. All patients underwent computed tomography angiography, MRI-T1W1, and contrast enhanced MRI-T1W1 image sequence scanning. The CT and MRI scanning data were collected and then imported into a Dextroscope imaging workstation, a virtual reality system that allows structures to be viewed stereoscopically. During preoperative assessment, typical images for each patient were chosen and printed out for use by the surgeons as references during surgery. RESULTS: All sellar tumor models clearly displayed bone, the internal carotid artery, circle of Willis and its branches, the optic nerve and chiasm, ventricular system, tumor, brain, soft tissue and adjacent structures. Depending on the location of the tumors, we simulated the transmononasal sphenoid sinus approach, transpterional approach, and other approaches. Eleven surgeons who used virtual reality models completed a survey questionnaire. Nine of the participants said that the virtual reality images were superior to other images but that other images needed to be used in combination with the virtual reality images. CONCLUSIONS: The three-dimensional virtual reality models were helpful for individualized planning of surgery in the sellar region. Virtual reality appears to be promising as a valuable tool for sellar region surgery in the future.

Acute Inpatient Rehabilitation Improves Function Independent of Comorbidities in Medically Complex Patients.

Objectives: (1) To evaluate the benefits of acute inpatient rehabilitation for a medically complex patient population and (2) to assess the effect of comorbid conditions on rehabilitation outcomes. Design: Retrospective cohort study. Setting: Freestanding inpatient rehabilitation facility. Participants: A total of 270 medically complex adult patients including those with cardiac, pulmonary, and orthopedic conditions, with mean age of 73.6 years; 52.6% were female and 47.4% were male (N=270). Interventions: Not applicable. Main Outcome Measures: Functional Independence Measure (FIM) gain, FIM efficiency, rehabilitation length of stay (RLOS), home discharge rate, and readmission to acute care (RTAC). Results: Among 270 medically complex patients, mean total FIM gain, mean RLOS, and mean FIM efficiency with SD were 26.0±13.6 points, 12.6±5.9 days, and 2.3±1.6, respectively. A total of 71.9% of patients were discharged to home, 12.2% for RTAC, and 15.9% to a skilled nursing facility (SNF). Hypertension (HTN) was the only comorbidity significantly associated with FIM gain (53.7% [total FIM gain ≥27] vs 67.2% [total FIM gain <27]; P=.024) and FIM efficiency (53.3% [FIM efficiency ≥2.12] vs 67.4% [FIM efficiency <2.12]; P=.025), independent of age, body mass index, sex, race, ethnicity, insurance type, and Charlson Comorbidity Index. The 5 most common reasons for RTAC were cardiac, pulmonary, acute blood loss anemia, infection, and neurologic conditions. Conclusions: Among 270 medically complex patients, 71.9% were discharged to home, 15.9% to an SNF, and 12.2% for RTAC with a mean RLOS 12.6 days, mean total FIM gain of 26 points, and mean FIM efficiency of 2.3, which were all better than those of all admissions at our facility in 2018. Furthermore, RLOS, total FIM gain and FIM efficiency in this study were all better than their corresponding eRehabData weighted national benchmarks (RLOS, 15.82 days; FIM gain, 25.57; FIM efficiency, 2.13) for a total of 202,520 discharges in 2018. These findings support acute inpatient rehabilitation for this patient population. With the exception of HTN, no medical comorbidities or demographic variables were associated with rehabilitation outcomes.

Investigating inpatient rehabilitation outcomes of patients with intensive care unit-acquired weakness, and identifying comorbidities associated with unfavorable outcomes.

INTRODUCTION: Data are consistent on the benefits of inpatient rehabilitation for intensive care unit-acquired weaknesses (ICUAW), including critical illness myopathy, critical illness polyneuropathy, critical illness polyneuromyopathy, and disuse atrophy. This study focuses on the effects of inpatient rehabilitation on patients with ICUAW, specifically those with a clinical pattern of proximal muscle weakness and sensory sparing. OBJECTIVES: To evaluate the impact of inpatient rehabilitation on patients with ICUAW versus other medically complex patients, and to identify comorbidities associated with poor rehabilitation outcomes. DESIGN: Retrospective cohort study. SETTING: Institutional, inpatient rehabilitation hospital. PATIENTS: Two hundred seventy adult patients (≥18 years) divided into two groups: diagnosis of ICUAW (N = 55) or otherwise medically complex (N = 215), and admitted under the care of one physiatrist. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: For all patients we compared functional independence measure (FIM) gain, FIM efficiency, rehabilitation length of stay (RLOS), discharge disposition, and major medical comorbidities. RESULTS: Patients with ICUAW had significantly greater FIM gain (P = .015) and RLOS (P = .02). There was no significant difference in FIM efficiency (P = .15). Patients with ICUAW had a significantly lower odds of acute hospital transfer (odds ratio [OR] = 0.52, with 95% confidence interval [CI] 0.47, 0.58) and skilled nursing facility discharge (OR = 0.19, with 95% CI 0.038, 0.95). However, patients with ICUAW did have a higher percent of acute hospital transfers than other medically complex patients (P = .017). In addition, patients with ICUAW were more medically complex, as evidenced by a significantly higher Charlson Comorbidity Index (P < .001), prevalence of anemia (P < .001), atrial fibrillation (P = .009), obstructive sleep apnea (P = .018), and bacteremia (P = .041). CONCLUSIONS: Patients with ICUAW with a clinical pattern of proximal muscle weakness and sensory sparing benefit from inpatient rehabilitation as evidenced by FIM gain and high home discharge rate. However, they have multiple medical comorbidities, which require judicious medical management and may contribute to a longer RLOS.

Cerebral venous hemodynamic responses in a mouse model of traumatic brain injury.

Traumatic brain injury (TBI) is a serious public health problem that endangers human health and is divided into primary and secondary injuries. Previous work has confirmed that changes in cerebral blood flow (CBF) are related to the progression of secondary injury, although clinical studies have shown that CBF monitoring cannot fully and accurately evaluate disease progression. These studies have almost ignored the monitoring of venous blood flow; however, as an outflow channel of the cerebral circulation, it warrants discussion. To explore the regulation of venous blood flow after TBI, the present study established TBI mouse models of different severities, observed changes in cerebral venous blood flow by laser speckle flow imaging, and recorded intracranial pressure (ICP) after brain injury to evaluate the correlation between venous blood flow and ICP. Behavioral and histopathological assessments were performed after the intervention. The results showed that there was a significant negative correlation between ICP and venous blood flow (r = -0.795, P < 0.01), and both recovered to varying degrees in the later stages of observation. The blood flow changes in regional microvessels were similar to those in venous, and the expression of angiogenesis proteins around the impact area was significantly increased. In conclusion, this study based on the TBI mouse model, recorded the changes in venous blood flow and ICP and revealed that venous blood flow can be used as an indicator of the progression of secondary brain injury.

Association Between Meeting Physical Activity Time-Intensity Guidelines With Ambulation, Quality of Life, and Inflammation in Claudication.

PURPOSE: The aim of this investigation was to determine if meeting the 2018 physical activity (PA) time-intensity guidelines was associated with better ambulatory function, health-related quality of life (HRQoL), vascular function, and inflammation than failing to meet the guidelines in patients with peripheral artery disease and claudication. Second, we determined the optimal number of total steps/d and steps taken at moderate cadence needed to meet the PA time-intensity guidelines. METHODS: Five hundred seventy-two patients were assessed on daily ambulatory activity for 1 wk with a step activity monitor, and were grouped according to whether they achieved <150 min/wk of moderate-intensity PA (group 1 = do not meet guidelines; n = 397) or whether they were above this threshold (group 2 = meet guidelines; n = 175). RESULTS: Treadmill peak walking time (mean ± SD) was higher ( P < .001) in group 2 (709 ± 359 sec) than in group 1 (427 ± 281 sec). The physical function HRQoL score was higher ( P < .001) in group 2 (61 ± 22%) than in group 1 (44 ± 21%). High-sensitivity C-reactive protein was lower ( P < .001) in group 2 (3.6 ± 4.5 mg/L) than in group 1 (5.9 ± 6.1 mg/L). Finally, ≥7675 total steps/d and ≥1660 steps/d at moderate cadence were optimal thresholds associated with meeting PA guidelines. CONCLUSIONS: Patients with claudication who meet the 2018 PA time-intensity guidelines for US adults had better ambulation, HRQoL, and vascular outcomes than those who failed to meet the PA guidelines. Patients with claudication best achieved the PA time-intensity guidelines by taking ≥7675 total steps/d, and ≥1660 steps/d at a moderate cadence.

Increased pulse wave velocity is related to impaired working memory and executive function in older adults with metabolic syndrome.

Age-related vascular alterations promote the pathogenesis of vascular cognitive impairment (VCI). Cardiovascular risk factors that accelerate vascular aging exacerbate VCI. Metabolic syndrome (MetS) constitutes a cluster of critical cardiovascular risk factors (abdominal obesity, hypertension, elevated triglycerides, elevated fasting glucose, reduced HDL cholesterol), which affects nearly 37% of the adult US population. The present study was designed to test the hypotheses that MetS exacerbates cognitive impairment and that arterial stiffening moderates the association between cognitive dysfunction and MetS in older adults. MetS was defined by the NCEP ATP III guidelines. Cognitive function (digit span and trail-making tests) and brachial-ankle pulse wave velocity (baPWV; a non-invasive clinical measurement of arterial stiffness) were assessed in older adults with MetS and age- and sex-matched controls. Multiple linear regression models were applied to test for the main effects of MetS, baPWV, and their interaction on cognitive performance. Fifty-three participants with MetS (age: 68 ± 8 years) and 39 age-matched individuals without MetS (age: 66 ± 9 years) were enrolled into the study. In adjusted multivariable regression analyses of the digit span backward length score, both MetS (ß = 1.97, p = 0.048) and MetS by baPWV interaction (ß = - 0.001, p = 0.026) were significant predictors. In participants with MetS, higher baPWV was associated with poorer performance on digit span backward length score, a test of working memory (R = - 0.44, p = 0.0012), but there was no association in those without MetS (R = 0.035, p = 0.83). MetS was negatively associated with performance on the digit span backward length score, baPWV was negatively associated with multiple neuropsychological outcomes, and baPWV moderated the association between digit span backward length score and MetS, as individuals with both MetS and higher baPWV had the most impaired cognitive function. Our findings add to the growing body of evidence that individuals with MetS and higher baPWV may be prone to VCI.

Chemotherapy-induced peripheral neuropathy and rehabilitation: A review.

Chemotherapy-induced peripheral neuropathy (CIPN) is a common complication after chemotherapy that can damage the sensory, motor, autonomic, or cranial nerves in approximately 30%-60% of patients with cancer. CIPN can lead to detrimental dose modifications and/or premature chemotherapy discontinuation due to patient intolerance. The long-term impact of CIPN is particularly challenging and can have a profound impact on the quality of life (QoL) and survivorship. However, this condition is often underdiagnosed. No agents have been established to prevent CIPN. Pre-chemotherapy testing is recommended for high-risk patients. Duloxetine is considered a first-line treatment, whereas gabapentin, pregabalin, tricyclic antidepressants, and topical compounding creams may be used for neuropathic pain control. Home-based, low-to-moderate walking, and resistance exercise during chemotherapy can reduce the severity and prevalence of CIPN symptoms, especially in older patients. Pre-habilitation and rehabilitation should be recommended for all patients receiving cytotoxic chemotherapies. The purpose of this article is to review common chemotherapeutic drugs causing CIPN, risk factors, diagnosis and treatment of CIPN, and evidence of the benefits of rehabilitation.

Factors Associated with the Development of Coagulopathy after Open Traumatic Brain Injury.

BACKGROUND: The incidence of coagulopathy after open traumatic brain injury (TBI) is high. Coagulopathy can aggravate intracranial hemorrhage and further increase morbidity and mortality. The purpose of this study was to determine the clinical characteristics of coagulopathy after open TBI and its relationship with the prognosis. METHODS: This study retrospectively evaluated patients with isolated open TBI from December 2018 to December 2020. Coagulopathy was defined as international normalized ratio (INR) > 1.2, activated thromboplastin time (APTT) > 35 s, or platelet count <100,000/µL. We compared the relationship between the clinical, radiological, and laboratory parameters of patients with and without coagulopathy, and the outcome at discharge. Logistic regression analysis was used to evaluate the risk factors associated with coagulopathy. We then compared the effects of treatment with and without TXA in open TBI patients with coagulopathy. RESULTS: A total of 132 patients were included in the study; 46 patients developed coagulopathy. Patients with coagulopathy had significantly lower platelet levels (170.5 × 109/L vs. 216.5 × 109/L, p < 0.001), and significantly higher INR (1.14 vs. 1.02, p < 0.001) and APTT (30.5 s vs. 24.5 s, p < 0.001) compared to those with no coagulopathy. A Low Glasgow Coma Scale (GCS) score, high neutrophil/lymphocyte ratio (NLR), low platelet/lymphocyte ratio (PLR), and hyperglycemia at admission were significantly associated with the occurrence of coagulopathy. CONCLUSIONS: Coagulopathy often occurs after open TBI. Patients with a low GCS score, high NLR, low PLR, and hyperglycemia at admission are at greater risk of coagulopathy, and therefore of poor prognosis. The efficacy of TXA in open TBI patients with coagulopathy is unclear. In addition, these findings demonstrate that PLR may be a novel indicator for predicting coagulopathy.

Daily Step Counts in Participants With and Without Peripheral Artery Disease.

PURPOSE: We compared the prevalence of participants with and without symptomatic peripheral artery disease (PAD) who met the goals of attaining >7000 and 10 000 steps/d, and we determined whether PAD status was significantly associated with meeting the daily step count goals before and after adjusting for demographic variables, comorbid conditions, and cardiovascular risk factors. METHODS: Participants with PAD (n = 396) and without PAD (n = 396) were assessed on their walking for 7 consecutive days with a step activity monitor. RESULTS: The PAD group took significantly fewer steps/d than the non-PAD control group (6722 ± 3393 vs. 9475 ± 4110 steps/d; P < .001). Only 37.6% and 15.7% of the PAD group attained the goals of walking >7000 and 10 000 steps/d, respectively, whereas 67.9% and 37.4% of the control group attained these goals (P < .001 for each goal). Having PAD was associated with a 62% lower chance of attaining 7000 steps/d than compared with the control group (OR = 0.383; 95% CI, 0.259-0.565; P < .001), and a 55% lower chance of attaining 10 000 steps/d (OR = 0.449; 95% CI, 0.282-0.709; P < .001). Significant covariates (P < .01) included age, current smoking, diabetes, and body mass index. CONCLUSIONS: Participants with symptomatic PAD had a 29% lower daily step count compared with age- and sex-matched controls, and were less likely to attain the 7000 and 10 000 steps/d goals. Additionally, participants who were least likely to meet the 7000 and 10 000 daily step count recommendations included those who were older, currently smoked, had diabetes, and had higher body mass index.

Risk factors for intrahepatic and extrahepatic cholangiocarcinoma: a case-control study in China.

BACKGROUND/AIMS: The risk factors for cholangiocarcinoma are incompletely defined in China, especially for intrahepatic cholangiocarcinoma (ICC). We evaluated the risk factors for both ICC and extrahepatic cholangiocarcinoma (ECC). METHODS: A case-control study in which cases were cholangiocarcinoma patients referred to Peking Union Medical College Hospital (PUMCH) between 1998 and 2008 and controls were healthy individuals. Controls were randomly selected from an existing database of healthy individuals at the Health Screening Center of PUMCH. Data on liver disease, family history, diabetes, smoking and drinking were collected by a retrospective review of the patients' records and health examination reports or by interview. RESULTS: A total of 190 patients (61 ICC; 129 ECC) and 380 age- and sex-matched controls were enrolled. HBsAg (P<0.001) and anti-HBc without HBsAg (P=0.001) were significantly related to ICC. The adjusted odds ratios (OR) and 95% confidence intervals (CI) were 18.1 (95% CI: 7.5-44.0) and 3.6 (95% CI: 1.7-7.6) respectively. Diabetes mellitus (P=0.007), cholecystolithiasis (P=0.004) and previous cholecystectomy (P<0.001) were significantly associated with ECC. The prevalence of cirrhosis was higher in ICC than that in ECC (P<0.001). Furthermore, on excluding the ICC patients with cirrhosis, ICC patients showed significant independent associations with HBsAg (OR: 7.3; 95% CI: 3.1-17.2) and anti-HBc without HBsAg (OR: 2.4; 95% CI: 1.1-5.2). CONCLUSION: Cirrhosis and chronic hepatitis B virus infection are risk factors for ICC, while cholecystolithiasis, diabetes and previous cholecystectomy are risk factors for ECC.

Cervical Dystonia Caused by Chronic Nonunion C2 Fracture: A Case Report.

Chronic nonunion cervical fracture leading to cervical dystonia (CD) is very rare. This study reports a 72-year-old man who presented with 9-month history of progressively worsening neck tilting, neck tightness, neck pain, headache, and difficulty with swallowing. The patient was referred to speech therapy and confirmed to have dysphagia on modified barium swallow study. A cervical spine radiograph showed a chronic C2 nonunion fracture. Subsequent cervical spine magnetic resonance imaging confirmed chronic C2 nonunion fracture with kyphotic deformity of the cervical canal with associated cord compression at C1-C2 and severe central canal stenosis. Needle electromyography revealed dystonic or spasmodic neck muscles, consistent with diagnosis of CD. Botulinum toxin injection resulted in marked clinical improvement. The patient finally underwent occipital to C4 posterior segmental fusion. No recurrence of CD had occurred 12 months after botulinum toxin injection and surgery, which supports the conclusion that chronic C2 nonunion fracture is most likely responsible for CD in this case. The authors suggest that all patients with CD receive dysphagia evaluation and more importantly cervical spine imaging to rule out chronic C2 nonunion fracture.

Influence of Self-Relevance and Reputational Concerns on Altruistic Moral Decision Making.

Complex moral decision making may share certain cognitive mechanisms with economic decision making under risk situations. However, it is little known how people weigh gains and losses between self and others during moral decision making under risk situations. The current study adopted the dilemma scenario-priming paradigm to examine how self-relevance and reputational concerns influenced moral decision making. Participants were asked to decide whether they were willing to sacrifice their own interests to help the protagonist (friend, acquaintance, or stranger) under the dilemmas of reputational loss risk, while the helping choices, decision times and emotional responses were recorded. In Study 1, participants showed a differential altruistic tendency, indicating that participants took less time to make more helping choices and subsequently reported weaker unpleasant experience toward friends compared to acquaintances and strangers. In Study 2, participants still made these egoistically biased altruistic choices under the low reputational loss risk conditions. However, such an effect was weakened by the high reputational loss risks. Results suggested that moral principle guiding interpersonal moral decision making observed in our study is best described as an egoistically biased altruism, and that reputational concerns can play a key role in restraining selfish tendency.

[Effect of silicosis alveolar macrophages on expression of c-myc in human embryo lung fibroblast in vitro].

OBJECTIVE: To study the effect of silicosis alveolar macrophages (AM) restimulated by SiO(2) on expression of c-myc oncogene in human embryo lung fibroblasts. METHODS: The bronchoalveolar lavage of silicosis patients was collected. AMs were divided into 2 groups: (1) SiO(2): AMs were stimulated with SiO(2) (30 microg/ml) for 1, 2, 6, 12, 24 and 36 h; (2) control: treated for the same time without SiO(2). Fibroblasts were cultured with different AMs supernatants for 2 h or 7 h respectively. The expression of c-myc mRNA was determined by RT-PCR and protein by Western Blot. RESULTS: There was no c-myc expression when fibroblasts were static. The supernatants in the S6 group stimulated expression of c-myc mRNA and protein, with the peak expression at 2 h and 7 h respectively. In the control group, AMs supernatants cultured in different time stimulated expression of c-myc mRNA and protein with the most evident expression at 12 h. The ratios were 0.749 +/- 0.088 and 0.759 +/- 0.101 respectively. Compared with control in the same period, c-myc mRNA and protein expression were significantly stronger treated with the supernatants in which AMs were stimulated for 1 h, 2 h and 6 h by SiO(2) (P < 0.05 or P < 0.01). CONCLUSION: AMs stimulated with SiO(2) has the ability to induce c-myc oncogene expression in human embryo lung fibroblasts.

Challenging Diagnosis and Inpatient Rehabilitation of Acute Bilateral Neuralgic Amyotrophy Possibly Attributed to Lyme Disease: A Case Report.

Neuralgic amyotrophy (NA) is a neurologic syndrome of unknown etiology primarily affecting the brachial plexus. We are reporting an unusual case of acute bilateral NA that was possibly secondary to Lyme disease. The patient demonstrated significant functional gains and was discharged home after 2 weeks of inpatient rehabilitation, supporting the role of inpatient rehabilitation in acute NA. In this report, we discuss the diagnosis, electrodiagnostic progression, pain management, goals for inpatient rehabilitation, and overall prognosis of NA. LEVEL OF EVIDENCE: V.

Management of Blood Blister-Like Aneurysms of the Internal Carotid Artery: Lessons Learned from Direct Clipping in 22 Cases.

OBJECTIVE: To present a case series of blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) and an assessment of diagnosis and treatment options, attempting to identify surgical or endovascular management of BBAs with a low complication rate and a functional outcome. METHODS: A retrospective analysis including diagnosis and treatment options of BBAs of the ICA was performed of patients treated for BBAs at Fuzhou General Hospital from January 2008 to September 2016. RESULTS: The case series includes 22 patients (14 women and 8 men) treated by direct clipping. Of all cases, 10 patients were successfully clipped; among them, 9 patients were cured with a favorable outcome, and 1 patient recovered but with slight disability. Among the other 12 cases with tear or avulsion of the BBA after clipping, the aneurysm and its parent artery had to be trapped in 9 cases. Complications in these 12 cases 3-14 days after surgery had led to ICA system occlusion on the BBA side, resulting in patient death in 9 cases, severe disability in 1 patient, persistent vegetative state in 1 patient, and 1 patient died 4 days later after bypass resurgery. CONCLUSIONS: Preoperative diagnosis of BBAs is essential for proper management. Once the BBA has ruptured, the emergency clipping operation should be performed with caution. Moreover, based on lessons learned from direct clipping and a literature review, interventional therapy appears to be a more physiologic and more definitive treatment option for BBAs of the ICA, with a more favorable patient outcome.