Multimodality Image-Guided Sclerotherapy of Low-Flow Orbital Vascular Malformations: Report of Single-Center Experience.

PURPOSE: To evaluate the role of multimodality imaging tools for intraprocedural guidance and outcome evaluation during sclerotherapy of low-flow orbital vascular malformations. MATERIALS AND METHODS: A retrospective review was performed of 17 consecutive patients with low-flow orbital malformations (14 lymphatic, two venous, and one venolymphatic) who underwent multimodality image-guided sclerotherapy between November 2012 and May 2015. Sclerotherapy technique, image guidance tools, and complications were recorded. Sclerotherapy outcome was evaluated using clinical response, magnetic resonance (MR) image-based lesion volumetry, and proptosis quantification. RESULTS: There were 22 sclerotherapy sessions performed. Intraprocedural ultrasound (US), fluoroscopy, cone-beam computed tomography (CT) and MR image fusion were used for image guidance with 100% technical success. Resolution of presenting symptoms was observed in all patients at 1-month follow-up. Four major sclerotherapy complications were successfully managed. Statistically significant reduction in lesion volume (P = .001) and proptosis (P = .0117) by MR image analysis was achieved in all patients in whom 3-month follow-up MR imaging was available (n = 13/17). There was no lesion recurrence at a median follow-up of 18 months (range, 8-38 mo). CONCLUSIONS: Multimodality imaging tools, including US, fluoroscopy, cone-beam CT, and MR fusion, during sclerotherapy of low-flow orbital malformations provide intraprocedural guidance and quantitative image-based evaluation of treatment outcome.

Characteristics and Outcomes of Middle East Respiratory Syndrome Coronavirus Patients Admitted to an Intensive Care Unit in Jeddah, Saudi Arabia.

BACKGROUND: An increasing number of patients are being infected with Middle East respiratory syndrome coronavirus (MERS-CoV) since the first case was identified in September 2012. We report the characteristics and outcomes of MERS-CoV-confirmed patients who developed critical illness requiring admission to an intensive care unit (ICU). METHODS: We conducted a prospective cohort study of all MERS-CoV-confirmed cases who were admitted to our ICU from March 20, 2014, till June 1, 2014. Presenting symptoms, comorbid conditions, and details of their ICU stay were recorded. RESULTS: Eight patients were admitted to the ICU with MERS-CoV infection. All had signs of respiratory distress with 7 requiring mechanical ventilation. Three patients were health care workers. In all, 6 patients had comorbid conditions and 5 patients developed multiorgan system failure (MOSF). In all, 5 patients expired, 2 were discharged alive, and 1 remained intubated at the end of the study period. CONCLUSIONS: Middle East respiratory syndrome coronavirus carries a high mortality rate in patients who require ICU admission, with a significant number of patients developing MOSF. Further investigation is needed to determine optimal management guidelines for these patients.

Workplace Violence and Self-reported Psychological Health: Coping with Post-traumatic Stress, Mental Distress, and Burnout among Physicians Working in the Emergency Departments Compared to Other Specialties in Pakistan.

BACKGROUND: Little is known about the mental health impact of workplace violence (WPV) among emergency physicians (EPs) working in emergency departments (EDs) in Pakistan and whether this impact varies across specialties. OBJECTIVES: Our aim was to measure the prevalence of WPV among EPs in 4 of the largest hospitals in Karachi, Pakistan; to measure the association between the experience of WPV and self-report of post-traumatic stress disorder (PTSD), depression, anxiety, and burnout; to compare the same factors across medical specialties; and to explore the coping strategies used by physicians in dealing with job-related stressors. METHODS: A cross-sectional survey was conducted among 179 physicians from 5 specialties (response rate, 92.2%) using standard questionnaires for WPV, PTSD, burnout, current mental distress, and methods of coping. RESULTS: One in 6 physicians reported experiencing a physical attack and 3 in 5 verbal abuse on the job in the previous 12 months. Pathologists were less likely to report any form of WPV compared to all other specialties. There was, however, no difference in experience of WPV between EPs and internists, surgeons, or pediatricians. One in 6 physicians screened positive for PTSD, and 2 in 5 for current anxiety and depression. There was significant comorbidity of mental distress with PTSD. Those who reported experiencing physical attack were 6.7 times more likely to report PTSD symptoms. We also found high rates of burnout (42.4% emotional exhaustion; 72.9% depersonalization) among physicians. CONCLUSION: Experience of WPV was not uniform across specialties but was generally high among Pakistani physicians. Prevention of WPV should be a high priority for health care policy makers.

Age-related differences in urinary 11-dehydroxythromboxane B2 between infants, children, and adolescents: another example of developmental hemostasis?

Our study was developed to ascertain reference ranges of 11-dehydrothromboxane B2 (11-dhTXB2) in the urine of healthy pediatric subjects. Urine samples were analyzed using the AspirinWorks™ assay that measures levels of 11-dehydrothromboxane B2. 128 individuals (2 months to 18 years) were identified as healthy and not receiving aspirin. When adjusted as picograms/milligrams urine creatinine, there was a negative correlation between age and level of 11-dehydrothromboxane B2 (P = 0.0001). This study confirms a negative correlation between age and level of urinary 11-dehydrothromboxane B2 and provides a set of age-specific reference ranges.

The Role of Sirtuin 1 (SIRT1) in Neurodegeneration.

Sirtuins (SIRT) are a class of histone deacetylases that regulate important metabolic pathways and play a role in several disease processes. Of the seven mammalian homologs currently identified, sirtuin 1 (SIRT1) is the best understood and most studied. It has been associated with several neurodegenerative diseases and cancers. As such, it has been further investigated as a therapeutic target in the treatment of disorders such as Parkinson's disease (PD), Huntington's disease (HD), and Alzheimer's disease (AD). SIRT1 deacetylates histones such as H1 lysine 26, H3 lysine 9, H3 lysine 56, and H4 lysine 16 to regulate chromatin remodeling and gene transcription. The homolog has also been observed to express contradictory responses to tumor suppression and tumor promotion. Studies have shown that SIRT1 may have anti-inflammatory properties by inhibiting the effects of NF-κB, as well as stimulating upregulation of autophagy. The SIRT1 activators resveratrol and cilostazol have been shown to improve Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) scores in AD patients. In this review, we aim to explore the various roles of SIRT1 with regard to neuroprotection and neurodegeneration.

Trans-splenic Access for Portal Venous Interventions in Children: Do Benefits Outweigh Risks?

BACKGROUND: The primary concern of trans-splenic access for portal interventions is the risk of life-threatening intraperitoneal bleeding. OBJECTIVE: To review the clinical indications and efficacy and evaluate the risk factors for intraperitoneal bleeding during trans-splenic portal interventions in children. MATERIALS AND METHODS: A retrospective review of consecutive patients who underwent trans-splenic portal interventions at a tertiary care pediatric institution between March 2011 and April 2017 was performed. Forty-four procedures were performed in 30 children with a median age of 5 (0.3-18) years. Clinical indications, technical success, procedural success, and incidence of complications were recorded. Potential risk factors for intraperitoneal bleeding were evaluated using Wilcoxon rank and Fisher's exact tests. RESULTS: Trans-splenic access was 100% successful. In 35/44 (79%) procedures, the subsequent intervention was successful including recanalization of post-transplant portal vein occlusion in 10/13, embolization of bleeding Roux limb varices in 8/8, recanalization of chronic portal vein thrombosis in native liver in 7/13, splenoportography and manometry in 6/6, and occlusion of portosystemic shunts in 4/4 procedures. Intraperitoneal bleeding occurred during 12/44 (27%) procedures and was managed with analgesics, blood transfusion, and peritoneal drainage without the need for splenectomy or splenic artery embolization. Statistically significant correlation of bleeding was found with intraprocedural anticoagulation, but not with patient age, weight, platelet count, INR, ascites, splenic length, splenic venous pressure, vascular sheath size, or tract embolization technique. CONCLUSION: Trans-splenic access is a useful technique for successful pediatric portal interventions. Although it entails a substantial risk of intraperitoneal bleeding, this can be managed conservatively.