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Objectives : The main objective of the study is to characterize the effects of genetic abnormalities/syndromes (GA/S) on perioperative outcomes of cardiac surgeries involving repair of conotruncal heart defects (CTHD). Design : The study involves a single-center retrospective analysis of patients who underwent complete repair of CTHDs (tetralogy of Fallot [TOF], truncus arteriosus, interrupted aortic arch, and ventricular septal defect with coarctation) between January 2000 and December 2015. The primary outcome was the post operative length of stay (PLOS). The secondary outcomes were mortality, cardiac complications, hematologic complications, infections, and number of medications-at-discharge. Setting : Cardiac intensive care unit in a tertiary pediatric hospital in South Florida that performs around 300 open-heart surgeries a year. Subjects : A total of 177 patients with CTHDs who underwent cardiac surgeries in the stated time period were included in the final study cohort. Measurements and Main Results :Majority of patients had TOF (72.5%) and 46 (26%) had GA/S. The most common GA/S was 22q11 deletion (37%). PLOS was significantly increased in patients with GA/S (P < 0.05). Patients with GA/S were 4.5 times more likely to have a postoperative cardiac complication, 4.2 times more likely to have a postoperative infection, and received 1.6 times more medications at discharge than those without GA/S. However, GA/S was not associated with increased perioperative mortality. Black patients were three times more likely to have a longer PLOS than White patients. Conclusions : Perioperative outcomes in patients with GA/S suggested an increased residual cardiovascular disease and increased resource usage. Notably, this is the first study demonstrating the effect of race and ethnicity on PLOS in CTHD patients.

Pustular psoriasis is a specialized variant of psoriasis which can be life threatening if not treated at the earliest. The pathogenesis has been recently linked to the role of interleukin 36. Apart from the corticosteroids, systemic antipsoriatics like acitretin, cyclosporine and methotrexate have been used with some success though unpredictable. With recent identification of role of IL-36 in the pathogenesis of pustular psoriasis, biologics targeting the IL-36 receptors have been used to manage the situation with high degree of success. This narrative review deals with the recent concepts of pathogenesis of pustular psoriasis as well as the current management scenario.

Psoriasis is a common chronic, immune-mediated inflammatory skin disease associated with various comorbidities. Managing psoriasis is often challenging as the therapy is decided based on the area of the disease, associated comorbidities and impairment in quality of life, besides the patient’s preference. Making progress in the development of new molecules that can be used topically or orally, effectively controlling the disease with minimal side effects and providing long-lasting remissions are the needs of the hour. Recent developments in understanding the complexities of the pathogenesis of psoriasis have resulted in the reinforcement of treatment modalities, leading to the evolution of various biologics and small-molecule inhibitors. In comparison with biologics, both patients and treating physicians prefer small molecules for various reasons such as avoiding injections and side effects that are associated with biologics biologics. Moreover small molecules are economical than biologics. Newer small molecules, both topical and oral, are promising additions to the therapeutic arsenal in the management of psoriasis in the future.

Intraductal papilloma of the breast is a rare benign tumour. The polypoid lesions arising from the nipple surface include papillomas and fibroepithelial stromal polyps. These lesions must be distinguished from malignant nipple lesions, such as Paget’s disease of the nipple or malignant breast conditions involving the nipple. Solitary papillomas (solitary intraductal papillomas) are single tumours that often grow in the large milk ducts near the nipple. They are a common cause of clear or bloody nipple discharge, especially when it comes from only one breast, and can be felt as a small lump behind or next to the nipple. Papillomas may also be found in small ducts in areas of the breast farther from the nipple. Multiple papillomas, which are growths that are less prone to generate nipple discharge, were present in this case. In papillomatosis, there are very small areas of cell growth within the ducts, but they aren’t as distinct as papillomas are. In order to distinguish between these disorders, a thorough clinical examination and imaging are essential. This case report describes a 36-year-old female who presented with swelling from the left nipple. Sonography of the left breast revealed a dilated duct in the left retro-areolar region with a focal isoechoic component within the duct {American College of Radiology Breast Imaging Reporting and Data System (ACR BI-RADS 4B)}. The patient underwent core excision of the duct, and histopathological analysis confirmed the diagnosis of papilloma with changes of adenosis without atypia.

The coronavirus SARS-CoV-2 causes the severe disease COVID-19. SARS-CoV-2 infection is initiated by interaction of the viral spike protein and host receptor angiotensin-converting enzyme 2 (ACE2). We report an improved bright and reversible fluorogenic reporter, named SURF (split UnaG-based reversible and fluorogenic protein-protein interaction reporter), that we apply to monitor real-time interactions between spike and ACE2 in living cells. SURF has a large dynamic range with a dark-to-bright fluorescence signal that requires no exogenous cofactors. Utilizing this reporter, we carried out a high-throughput screening of small-molecule libraries. We identified three natural compounds that block replication of SARS-CoV-2 in both Vero cells and human primary nasal and bronchial epithelial cells. Cell biological and biochemical experiments validated all three compounds and showed that they block the early stages of viral infection. Two of the inhibitors, bruceine A and gamabufotalin, were also found to block replication of the Delta and Omicron variants of SARS-CoV-2. Both bruceine A and gamabufotalin exhibited potent antiviral activity in K18-hACE2 and wild-type C57BL6/J mice, as evidenced by reduced viral titres in the lung and brain, and protection from alveolar and peribronchial inflammation in the lung, thereby limiting disease progression. We propose that our fluorescent assay can be applied to identify antiviral compounds with potential as therapeutic treatment for COVID-19 and other respiratory diseases.

**Introduction**: The New Zealand Accidents Compensation Corporation received 28,901 new claims for maxillofacial fractures between January 2018 and December 2021, at an annual cost of NZ$70–80 million. We have previously reported interpersonal violence as the most common cause of maxillofacial fractures disproportionately affecting young Māori males. This study provides an update on the incidence and cause of maxillofacial fractures with a specific review of the impact of COVID-19 lockdowns. **Methods**: Patients referred to the Wellington Regional Plastic, Maxillofacial and Burns Unit from 1 January 2018 to 31 December 2021 were identified from our maxillofacial fracture database. Age, ethnicity, gender, cause of injury, risk factors, and fracture pattern and management were analysed. **Results**: Out of 1281 patients identified, 75.2 per cent were male, most commonly (38.7%) aged 16–30 years. Interpersonal violence, falls and sports accounted for 37.6 per cent, 24.9 per cent, and 24.0 per cent of all maxillofacial fractures, respectively. Māori (22.0%) and New Zealand Europeans (55.7%) were the two largest groups, most commonly affected by interpersonal violence and falls, respectively. There was a relative increase in referral rates for females and for those older than 60 years (1.78 per 10 person-days versus 0.014 per 10 person-days and 4.2 per 10 person-days versus 1.8 per 10 person-days, respectively) and a decrease in the rates of interpersonal violence and sports related referrals (1.2 per 10 person-days versus 3.4 per 10 person-days and 0.41 per 10 person-days versus 2.19 per 10 person-days, respectively) during COVID-19 lockdowns, compared with outside lockdown. **Conclusions**: Interpersonal violence remains the main cause of maxillofacial fractures. There is a need for a national prevention strategy to reduce this. During COVID-19 lockdowns, there was a relative increase in the referral rates of females aged 60 years and over. Both sports and interpersonal violence showed significantly reduced referral rates during lockdowns, while falls, road traffic accidents and other were referred at a similar rate as out of lockdown.

Purpose: Foreign body reaction to non-absorbable alloplastic orbital implants utilized for bony reconstruction are infrequently documented in the literature. We present the workup and surgical management of a giant cystic mass encapsulating a patient's alloplastic orbital implant, which was ultimately deemed to be a result of foreign body reaction. Observations: A 41-year-old male patient with distant history of a right orbital floor fracture had undergone repair with the placement of a nylon foil implant. The patient presented twenty years later with progressive ipsilateral globe proptosis and was found to have a giant inferior orbital cyst. Surgical exploration and removal of the implant and capsule were performed. Histopathology confirmed a delayed foreign body reaction around the patient's alloplastic implant. Conclusions: Alloplastic implants may result foreign body reaction and cyst encapsulation as a delayed complication.

Lumbar incisional hernia is an uncommon complication that affects the abdominal wall integrity, accounting for approximately 3.5% of all cases. It typically occurs following open nephrectomy or aortic aneurysm repair surgeries. Although rare, lumbar hernias can lead to discomfort, aesthetic issues, or even intestinal obstruction. In extremely rare cases, lumbar herniation of the liver can occur. Here, the authors present a case of a 60-year-old female patient with liver herniation through a lumbar incisional hernia and a history of pyelolithotomy for renal calculi. The authors performed an open hernia repair with meshplasty. Lumbar incisional hernias are rare and still difficult to manage. Computed tomography is the diagnostic method of choice in the evaluation of the parietal wall defect to choose the appropriate therapeutic management. Surgical management modalities are still poorly codified, with no precise recommendations, and this is probably due to the relative rarity of the cases.

In the paradigm of Device-to-Device (D2D) and System-on-Chip (SoC) communications, the optimization of high-speed data transfer while minimizing hardware resource utilization imposing paramount importance. Traditional methodologies have often resulted in undesirable outcomes, such as inflated area, latency, and power consumption. Consequently, this study adopts a focused approach by introducing an innovative Route-Controlling Network-on-Chip (RC-NoC) architecture, integrating critical components like FIFO-Buffer, crossbar switching, route control, and arbiter modules. The operational sequence begins with the FIFO-Buffer logic, which strategically manages data storage from diverse devices, allocating and organizing data flow based on distinct IP addresses. Subsequently, the route controller module orchestrates the operation of heterogeneous routers within the crossbar switching fabric, implementing a prioritized scheduling scheme. The arbiter plays a crucial role in overseeing and directing data flow from source to destination, leveraging request-level prioritization for efficient data transmission. Empirical evidence from simulations unequivocally demonstrates the superiority of the proposed RC-NoC architecture. Comparative analysis against essential state-of-the-art NoC architectures reveals significant enhancements in key metrics, notably area efficiency, latency reduction, and power optimization, with over 45% improvement observed across these metrics compared to GALS-NoC, F-NoC, and CE-NoC in the Orion framework. This robust validation substantiates the efficacy and technical prowess of the RC-NoC design paradigm in addressing the challenges of modern D2D and SoC communication paradigms. Furthermore, the optimization process notably decreased routing costs for different packets, with Router2 exhibiting a 40% reduction in Packet1’s routing cost and Router3 displaying a 44% decrease in Packet2’s cost. Moreover, the attained router capacities demonstrated an average increase of 17%, significantly enhancing network efficiency.

Myxofibrosarcoma is an aggressively malignant soft-tissue neoplasm of the upper or lower extremities that occurs in adults. At the time of diagnosis, upto 73% of cancer patients complain of varying degrees of pain. The ultimate goal of treatment is pain relief and functional recovery. The authors describe the case of a 59-year-old female patient who presented with complaints of excruciating brachialgia of the right upper limb. She had a pain score of 10 based on the Visual Analogue Scale (VAS 0-10). Her pain was initially managed conservatively with systemic analgesics but it failed to offer adequate relief. Often, there is an inadequate response to conservative treatment. These patients may benefit from various interventional modalities. Hence, epidural neurolysis with phenol was done by slowly injecting 2 mL of 6% aqueous phenol into the epidural space under Computed Tomography (CT) and fluoroscopy guidance. Upon follow-up, the patient’s Visual Analog Scale (VAS) was recorded as one, morphine consumption decreased with eventual discontinuation, and paraesthesia had reduced by 50%. This patient was suffering from chronic pain, which significantly reduced her Quality of Life (QoL). The injection of phenol into the appropriate space resulted in satisfactory sustained analgesia. She did not have any sensory or motor loss. Her pain was adequately controlled by paracetamol 500 mg as needed. The patient remained pain-free for five months after the procedure but eventually succumbed to her illness.

Objective: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) is highly contagious. The use of other barrier techniques, in addition to personal protective equipment (PPE), to limit aerosolization and protect against contamination may also be helpful. Design: This is a prospective, randomized, single-blind, comparative study to compare the efficacy of aerosol box with the Mayo trolley containment setup during intubation. Materials and Methods: The two setups were compared for ease and time taken for intubation, restriction of hand movement, difficulty in accessing equipment, difficulty in railroading of endotracheal tube (ETT) over a bougie, and general satisfaction of operator during intubation using the C-MAC video laryngoscope. The mean time taken for endotracheal intubation (ETI) was compared using the unpaired t-test, and the rest of the categorical variables were presented as proportions and percentages. Results: The mean time taken for ETI using the Mayo trolley was 42.6 seconds as compared to 54.5 seconds with an aerosol box. The operator was more satisfied with the Mayo trolley setup. Conclusion: The Mayo trolley containment setup is an inexpensive and readily available alternative to the aerosol box in any setting, with a lesser time taken to intubation and lesser restriction of hand movement, easy accessibility of equipment, and easy railroading of ETT over a bougie.

Foreign body retention in the neck may be either traumatic or iatrogenic. Penetrating neck injuries with retained bodies are critical, as the neck serves as a passage for structures essential to life. Therefore, prompt detection and retrieval of the foreign body are paramount in preventing mortality. Here, authors present a case in which a successful surgical retrieval was performed without any postprocedural complications, despite the patient presenting relatively late after the injury. In this case report, a 23-year-old male labourer presented with a right-sided neck swelling two months after a workplace injury involving a shattered metal plate. Imaging confirmed a 15×5 mm hyperdense metallic object penetrating the sternocleidomastoid muscle. Successful open exploration extracted a 1.5 cm metallic shard at the C6 vertebral level, with no major vessel or airway damage. Postoperatively, the patient exhibited no movement restrictions, highlighting the atypical presentation of a retained metallic foreign body and the importance of timely intervention and comprehensive imaging for successful management.

Abstract With concurrent global epidemics of chronic pain and opioid use disorders, there is a critical need to identify, target and manipulate specific cell populations expressing the mu-opioid receptor (MOR). However, available tools and transgenic models for gaining long-term genetic access to MOR+ neural cell types and circuits involved in modulating pain, analgesia and addiction across species are limited. To address this, we developed a catalog of MOR promoter (MORp) based constructs packaged into adeno-associated viral vectors that drive transgene expression in MOR+ cells. MORp constructs designed from promoter regions upstream of the mouse Oprm1 gene (mMORp) were validated for transduction efficiency and selectivity in endogenous MOR+ neurons in the brain, spinal cord, and periphery of mice, with additional studies revealing robust expression in rats, shrews, and human induced pluripotent stem cell (iPSC)-derived nociceptors. The use of mMORp for in vivo fiber photometry, behavioral chemogenetics, and intersectional genetic strategies is also demonstrated. Lastly, a human designed MORp (hMORp) efficiently transduced macaque cortical OPRM1+ cells. Together, our MORp toolkit provides researchers cell type specific genetic access to target and functionally manipulate mu-opioidergic neurons across a range of vertebrate species and translational models for pain, addiction, and neuropsychiatric disorders.

Understanding viral tropism is an essential step toward reducing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, decreasing mortality from coronavirus disease 2019 (COVID-19) and limiting opportunities for mutant strains to arise. Currently, little is known about the extent to which distinct tissue sites in the human head and neck region and proximal respiratory tract selectively permit SARS-CoV-2 infection and replication. In this translational study, we discover key variabilities in expression of angiotensin-converting enzyme 2 (ACE2) and transmembrane serine protease 2 (TMPRSS2), essential SARS-CoV-2 entry factors, among the mucosal tissues of the human proximal airways. We show that SARS-CoV-2 infection is present in all examined head and neck tissues, with a notable tropism for the nasal cavity and tracheal mucosa. Finally, we uncover an association between smoking and higher SARS-CoV-2 viral infection in the human proximal airway, which may explain the increased susceptibility of smokers to developing severe COVID-19. This is at least partially explained by differences in interferon (IFN)-β1 levels between smokers and non-smokers.

The respiratory disease COVID-19 is caused by the coronavirus SARS-CoV-2. Here we report the discovery of ethacridine as a potent drug against SARS-CoV-2 (EC50 ~ 0.08 μM). Ethacridine was identified via high-throughput screening of an FDA-approved drug library in living cells using a fluorescence assay. Plaque assays, RT-PCR and immunofluorescence imaging at various stages of viral infection demonstrate that the main mode of action of ethacridine is through inactivation of viral particles, preventing their binding to the host cells. Consistently, ethacridine is effective in various cell types, including primary human nasal epithelial cells that are cultured in an air-liquid interface. Taken together, our work identifies a promising, potent, and new use of the old drug via a distinct mode of action for inhibiting SARS-CoV-2.

ObjectiveMulti-center implementation of rapid whole genome sequencing with assessment of the clinical utility of rapid whole genome sequencing (rWGS), including positive, negative and uncertain results, in admitted infants with a suspected genetic disease.Study designrWGS tests were ordered at eight hospitals between November 2017 and April 2020. Investigators completed a survey of demographic data, Human Phenotype Ontology (HPO) terms, test results and impacts of results on clinical care.ResultsA total of 188 patients, on general hospital floors and intensive care unit (ICU) settings, underwent rWGS testing. Racial and ethnic characteristics of the tested infants were broadly representative of births in the country at large. 35% of infants received a diagnostic result in a median of 6 days. The most common HPO terms for tested infants indicated an abnormality of the nervous system, followed by the cardiovascular system, the digestive system, the respiratory system and the head and neck. Providers indicated a major change in clinical management because of rWGS for 32% of infants tested overall and 70% of those with a diagnostic result. Also, 7% of infants with a negative rWGS result and 23% with a variant of unknown significance (VUS) had a major change in management due to testing.ConclusionsOur study demonstrates that the implementation of rWGS is feasible across diverse institutions, and provides additional evidence to support the clinical utility of rWGS in a demographically representative sample of admitted infants and includes assessment of the clinical impact of uncertain rWGS results in addition to both positive and negative results.

Emerging evidence points toward an intricate relationship between the pandemic of coronavirus disease 2019 (COVID-19) and diabetes. While preexisting diabetes is associated with severe COVID-19, it is unclear whether COVID-19 severity is a cause or consequence of diabetes. To mechanistically link COVID-19 to diabetes, we tested whether insulin-producing pancreatic β cells can be infected by SARS-CoV-2 and cause β cell depletion. We found that the SARS-CoV-2 receptor, ACE2, and related entry factors (TMPRSS2, NRP1, and TRFC) are expressed in β cells, with selectively high expression of NRP1. We discovered that SARS-CoV-2 infects human pancreatic β cells in patients who succumbed to COVID-19 and selectively infects human islet β cells in vitro. We demonstrated that SARS-CoV-2 infection attenuates pancreatic insulin levels and secretion and induces β cell apoptosis, each rescued by NRP1 inhibition. Phosphoproteomic pathway analysis of infected islets indicates apoptotic β cell signaling, similar to that observed in type 1 diabetes (T1D). In summary, our study shows SARS-CoV-2 can directly induce β cell killing.

Acne vulgaris is one of the most common disorders of the pilosebaceous unit, affecting around 9.4% of the global population. The principal or preliminary lesions of acne are comedones, which represent the follicular dilation and hypercornification secondary to androgen hypersensitivity. Although the diagnosis of acne is rarely difficult for an experienced dermatologist, we rarely come across various other dermatoses that clinically resemble comedones yet have a different pathophysiology and poorly respond to treatment. Not all disorders that have comedone-like lesions are acne. These disorders should be kept in mind when comedones occur in an unusual site, age, or pattern. This review article mainly focuses and highlights the salient features of multiple non-acne disorders that present with open comedone-like lesions along with an approach to the diagnosis and its management.

The coronavirus SARS-CoV-2 is the causative agent of the ongoing severe acute respiratory disease pandemic COVID-19. Tissue and cellular tropism is one key to understanding the pathogenesis of SARS-CoV-2. We investigate the expression and subcellular localization of the SARS-CoV-2 receptor, angiotensin-converting enzyme 2 (ACE2), within the upper (nasal) and lower (pulmonary) respiratory tracts of human donors using a diverse panel of banked tissues. Here, we report our discovery that the ACE2 receptor protein robustly localizes within the motile cilia of airway epithelial cells, which likely represents the initial or early subcellular site of SARS-CoV-2 viral entry during host respiratory transmission. We further determine whether ciliary ACE2 expression in the upper airway is influenced by patient demographics, clinical characteristics, comorbidities, or medication use, and show the first mechanistic evidence that the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) does not increase susceptibility to SARS-CoV-2 infection through enhancing the expression of ciliary ACE2 receptor. These findings are crucial to our understanding of the transmission of SARS-CoV-2 for prevention and control of this virulent pathogen.

BackgroundEndoscopic endonasal approaches pose the potential risk of olfactory loss. Loss of olfaction and potentially taste can be permanent and greatly affect patients' quality of life. Treatments for olfactory loss have had limited success. Omega-3 supplementation may be a therapeutic option with its effect on wound healing and nerve regeneration.ObjectiveTo evaluate the impact on olfaction in patients treated with omega-3 supplementation following endoscopic skull base tumor resection.MethodsIn this multi-institutional, prospective, randomized controlled trial, 110 patients with sellar or parasellar tumors undergoing endoscopic resection were randomized to nasal saline irrigations or nasal saline irrigations plus omega-3 supplementation. The University of Pennsylvania Smell Identification Test (UPSIT) was administered preoperatively and at 6 wk, 3 mo, and 6 mo postoperatively.ResultsEighty-seven patients completed all 6 mo of follow-up (41 control arm, 46 omega-3 arm). At 6 wk postoperatively, 25% of patients in both groups experienced a clinically significant loss in olfaction. At 3 and 6 mo, patients receiving omega-3 demonstrated significantly less persistent olfactory loss compared to patients without supplementation (P = .02 and P = .01, respectively). After controlling for multiple confounding variables, omega-3 supplementation was found to be protective against olfactory loss (odds ratio [OR] 0.05, 95% CI 0.003-0.81, P = .03). Tumor functionality was a significant independent predictor for olfactory loss (OR 32.7, 95% CI 1.15-929.5, P = .04).ConclusionOmega-3 supplementation appears to be protective for the olfactory system during the healing period in patients who undergo endoscopic resection of sellar and parasellar masses.

Choledochal cyst is a congenital disease of the biliary tract with extrahepatic and/or intrahepatic biliary tree dilatation. There is a female majority (4:1). Controlling biliary sepsis and curing pancreatitis are prerequisites of surgery. Here, a 35-year-old female patient, came with complaints of epigastric and right upper abdominal pain for three days. On examination per abdomen was soft, non distended, right hypochondriac tenderness was present, no guarding, bowel sounds were audible. Magnetic Resonance Cholangiopancreatography (MRCP) was done which showed fusiform dilatation of Common Bile Duct (CBD), Common Hepatic Duct (CHD), right and left hepatic duct, along with mild dilatation of central intrahepatic biliary radicals (4.8-5 mm)- suggestive of choledochal cyst type IVA. Hepatico-duodenostomy was done. The entire extrahepatic biliary tree should be removed when the choledochal cyst is diagnosed whether or not symptoms are present. Despite being congenital, the condition is typically discovered in adulthood as well. The treatment of choledochal cysts has evolved. The current standard of care is cyst excision and hepaticojejunostomy.

Key Clinical Message We report two, genotypically identical but phenotypically distinct cases of Schaaf‐Yang syndrome and propose the early use of Genome Sequencing in patients with nonspecific presentations to facilitate the early diagnosis of children with rare genetic diseases and improve overall health care outcomes.

Abstract Recurrence and biochemical remission rates vary widely among different histological subtypes of pituitary adenoma. In this prospective study, we evaluated 107 consecutive primary pituitary adenomas operated on by a single neurosurgeon including 28 corticotroph, 27 gonadotroph, 24 somatotroph, 17 lactotroph, 5 null-cell and 6 plurihormonal. In each case, we performed direct endoscopic intraoperative inspection of the medial wall of the cavernous sinus, which was surgically removed when invasion was visualized. This was performed irrespective of tumor functional status. Medial wall resection was performed in 47% of pituitary adenomas, and 39/50 walls confirmed pathologic evidence of invasion, rendering a positive predictive value of intraoperative evaluation of medial wall invasion of 78%. We show for the first-time dramatic disparities in the frequency of medial wall invasion among pathological subtypes. Somatotroph tumors invaded the medial wall much more often than other adenoma subtypes, 81% intraoperatively and 69% histologically, followed by plurihormonal tumors (40%) and gonadotroph cell tumors (33%), both with intraoperative positive predictive value of 100%. The least likely to invade were corticotroph adenomas, at a rate of 32% intraoperatively and 21% histologically, and null-cell adenomas at 0%. Removal of the cavernous sinus medial wall was not associated with permanent cranial nerve morbidity nor carotid artery injury, although 4 patients (all Knosp 3-4) experienced transient diplopia. Medial wall resection in acromegaly resulted in the highest potential for biochemical remission ever reported, with an average postoperative day 1 GH levels of 0.96 ug/L and surgical remission rates of 92% based on normalization of IGF-1 levels after surgery (mean = 15.56 months; range 3–30 months). Our findings suggest that tumor invasion of the medial wall of the cavernous sinus may explain the relatively low biochemical remission rates currently seen for acromegaly and illustrate the relevance of advanced intradural surgical approaches for successful and durable outcomes in endonasal pituitary surgery for functional adenomas.

ObjectiveSeveral small case series identified KCTD7 mutations in patients with a rare autosomal recessive disorder designated progressive myoclonic epilepsy (EPM3) and neuronal ceroid lipofuscinosis (CLN14). Despite the name KCTD (potassium channel tetramerization domain), KCTD protein family members lack predicted channel domains. We sought to translate insight gained from yeast studies to uncover disease mechanisms associated with deficiencies in KCTD7 of unknown function.MethodsNovel KCTD7 variants in new and published patients were assessed for disease causality using genetic analyses, cell-based functional assays of patient fibroblasts and knockout yeast, and electron microscopy of patient samples.ResultsPatients with KCTD7 mutations can exhibit movement disorders or developmental regression before seizure onset, and are distinguished from similar disorders by an earlier age of onset. Although most published KCTD7 patient variants were excluded from a genome sequence database of normal human variations, most newly identified patient variants are present in this database, potentially challenging disease causality. However, genetic analysis and impaired biochemical interactions with cullin 3 support a causal role for patient KCTD7 variants, suggesting deleterious alleles of KCTD7 and other rare disease variants may be underestimated. Both patient-derived fibroblasts and yeast lacking Whi2 with sequence similarity to KCTD7 have impaired autophagy consistent with brain pathology.InterpretationBiallelic KCTD7 mutations define a neurodegenerative disorder with lipofuscin and lipid droplet accumulation but without defining features of neuronal ceroid lipofuscinosis or lysosomal storage disorders. KCTD7 deficiency appears to cause an underlying autophagy-lysosome defect conserved in yeast, thereby assigning a biological role for KCTD7. Ann Neurol 2018;84:774-788.

Objective Patients commonly use the Internet to obtain their health-related information. The purpose of this study was to investigate the quality, accuracy, and readability of online patient resources for the management of articular cartilage defects. Design Three search terms ("cartilage defect," "cartilage damage," "cartilage injury") were entered into 3 Internet search engines (Google, Bing, Yahoo). The first 25 websites from each search were collected and reviewed. The quality and accuracy of online information were independently evaluated by 3 reviewers using predetermined scoring criteria. The readability was evaluated using the Flesch-Kincaid (FK) grade score. Results Fifty-three unique websites were evaluated. Quality ratings were significantly higher in websites with a FK score >11 compared to those with a score of ≤11 ( P = 0.021). Only 10 websites (19%) differentiated between focal cartilage defects and diffuse osteoarthritis. Of these, 7 (70%) were elicited using the search term "cartilage defect" ( P = 0.038). The average accuracy of the websites was high (11.7 out of maximum 12), and the average FK grade level (13.4) was several grades higher than the recommended level for readable patient education material (eighth grade level). Conclusions The quality and readability of online patient resources for articular cartilage defects favor those with a higher level of education. Additionally, the majority of these websites do not distinguish between focal chondral defects and diffuse osteoarthritis, which can fail to provide appropriate patient education and guidance for available treatment. Clinicians should help guide patients toward high-quality, accurate, and readable online patient education material.

Balanoposthitis is a common inflammatory condition of the glans and prepuce among sexually active men in sexually transmitted diseases clinics. The common causes of this condition are infective, most commonly candidal, followed by bacterial and inflammatory. Among young uncircumcised men who are not sexually active, balanoposthitis may be the first clinical sign of underlying Type II diabetes mellitus (DM). Here, we present one such patient who presented with balanoposthitis and penile cellulitis. On initial workup, he was found to be a diabetic with poor control (HbA1c 11%), and on further investigations, he was found to have Staphylococcal balanoposthitis. He was initially managed with intravenous antibiotics, insulin therapy, and a dorsal slit of the prepuce, followed by circumcision, insulin, and oral hypoglycemic agents. DM should be suspected in all uncircumcised males presenting with balanoposthitis in the absence of positive contact history.

Abstract We report two siblings with intractable epilepsy, developmental regression, and progressive cerebellar atrophy due to biallelic variants in the gene CAD. For the affected girl, uridine started at age 5 resulted in dramatic improvements in seizure control and development, cessation of cerebellar atrophy, and resolution of hematological abnormalities. Her older brother had a more severe course and only modest response to uridine started at 14 years old. Treatment of this progressive condition via uridine supplementation provides an example of precision diagnosis and treatment using clear outcome measures and biomarkers to monitor efficacy.

Syngnathia is an extremely rare craniofacial malformation affecting the upper and lower jaws, in particular, and adjacent bony and soft tissues, to lesser or greater extent. Fusion of jaws leads to complications such as compromised airway and breathing, feeding difficulty, and poor growth. An early multidisciplinary intervention, surgery at the appropriate time, and meticulous postoperative monitoring are most imperative in its management. We describe a case of a 6-month-old child with congenital syngnathia that was managed successfully. Four-year follow-up revealed satisfactory outcomes and the need for corrective jaw surgeries after growth completion for improved function and esthetics. Anesthesia considerations, feeding, surgical management, postoperative care, and follow-up as well as growth regulation have been discussed in detail.

Context: Lung transplantation (LT) is now being performed for end-stage lung and heart-lung disease in a few centers in India. Experience in multidetector computed tomography (MDCT) evaluation of posttransplant complications is currently limited and evolving. Aims: This study analyses the early experience in our center regarding the imaging features of complications following LT with clinical outcome correlation and identify the role of MDCT. Methodology: A retrospective study of patients who underwent LT and had MDCT imaging from January 2017 to March 2019 was performed. There were 22 patients in this period whose clinical course and CT scans were studied. Results: The complications encountered include pleural effusions, atelectasis, bronchostenosis, and reperfusion injury. Rare complications included pulmonary thromboembolism and rejection. The accuracy of computed tomography (CT) imaging in airway evaluation was high but was limited in characterization of consolidation as either infective or noninfective. Conclusions: CT is the noninvasive imaging modality of choice in evaluating chronic rejection, airway complications such as bronchostenosis and pulmonary thromboembolism. Clinical, laboratory, and biopsy correlation are needed to diagnose infection or acute rejection, both of which can present with consolidation. Temporal evaluation of events is critical. Familiarity and awareness by the radiologist are crucial for good clinical outcome.

Local anesthetics with long-lasting effects and selectivity for nociceptors have been sought over the past decades. In this study, we investigated whether amiodarone, a multiple channel blocker, provides long-lasting local anesthesia and whether adding a TRPV1 channel activator selectively prolongs sensory anesthetic effects without prolonging motor blockade. Additionally, we examined whether amiodarone provides long-lasting analgesic effects against inflammatory pain without TRPV1 channel activator co-administration. In the sciatic nerve block model, 32 adult C57BL/6J mice received either bupivacaine, amiodarone with or without capsaicin (a TRPV1 agonist), or vehicle via peri-sciatic nerve injection. Sensory and motor blockade were assessed either by pinprick and toe spread tests, respectively. In another set of 16 mice, inflammatory pain was induced in the hind paw by zymosan injection, followed by administration of either amiodarone or vehicle. Mechanical and thermal sensitivity and paw thickness were assessed using the von Frey and Hargreaves tests, respectively. The possible cardiovascular and neurological side effects of local amiodarone injection were assessed in another set of 12 mice. In the sciatic nerve block model, amiodarone produced robust anesthesia, and the co-administration of TRPV1 agonist capsaicin prolonged the duration of sensory blockade, but not that of motor blockade [complete sensory block duration: 195.0 ± 9.8 min vs. 28.8 ± 1.3 min, F (2, 21) = 317.6, p < 0.01, complete motor block duration: 27.5 ± 1.6 min vs. 21.3 ± 2.3 min, F (2, 22) = 11.1, p = 0.0695]. In the zymosan-induced inflammatory pain model, low-dose amiodarone was effective in reversing the mechanical and thermal hypersensitivity not requiring capsaicin co-administration [50% withdrawal threshold at 8 h (g): 0.85 ± 0.09 vs. 0.25 ± 0.08, p < 0.01, withdrawal latency at 4 h (s) 8.5 ± 0.5 vs. 5.7 ± 1.4, p < 0.05]. Low-dose amiodarone did not affect zymosan-induced paw inflammation. Local amiodarone did not cause cardiovascular or central nervous system side effects. Amiodarone may have the potential to be a long-acting and nociceptor-selective local anesthetic and analgesic method acting over open-state large-pore channels.

A patient had a stroke caused by a large, pedunculated aortic ascending mass and was deemed at high risk for near-term recurrent stroke. This case illustrates percutaneous aspiration thrombectomy of ascending aortic thrombus with the AngioVac system (Angiodynamics, Latham, New York), with conscious sedation for early stroke detection and with endovascular cerebral embolic protection. (Level of Difficulty: Intermediate.)

Understanding how SARS-CoV-2 gains initial entry into the human body is a key step towards the development of prophylaxes and therapeutics for COVID-19. Here, the authors show that ACE2, the receptor for SARS-CoV-2, is abundantly expressed in the motile cilia of the human nasal and respiratory tract and is not affected by the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers.

BackgroundYoung sexual and gender minorities (SGMs) of color may face unique experiences of discrimination based on their intersectional positions (eg, discrimination based on both racial or ethnic identity and sexual identity). Emerging evidence suggests that mindfulness practices may reduce stress from discrimination and improve overall well-being among young SGM. Moreover, the omnipresence of smartphone access among racial or ethnic and sexual minority communities provides a method through which to administer mindfulness-based interventions among young SGMs of color. ObjectiveThis paper outlines the protocol of the Optimizing a Daily Mindfulness Intervention to Reduce Stress from Discrimination among Young Sexual and Gender Minorities of Color (REDUCE) study, a pilot optimization trial of a smartphone-based mindfulness intervention that was developed in conjunction with the Healthy Minds Program (HMP) with the aim of reducing stress from discrimination among young SGMs. MethodsIn total, 80 young (ages 18-29 years) SGMs of color will be enrolled in the study. The HMP is a self-guided meditation practice, and participants will be randomized to either a control condition or an intervention that uses a neuroscience-based approach to mindfulness. We will use the multiphase optimization strategy to assess which combination of mindfulness interventions is the most effective at reducing stress from discrimination among young SGMs of color. A combination of mindfulness-based meditation intervention components will be examined, comprising mindfulness-based practices of awareness, connection, and purpose. Awareness refers to the practice of self-awareness, which reduces the mind’s ability to be distracted and instead be present in the moment. Connection refers to the practice of connection with oneself and others and emphasizes on empathy and compassion with oneself and others. Purpose encourages goal-making in accordance with one’s values and management of behavior in accordance with these goals. In addition, we will assess the feasibility and acceptability of the HMP application among young SGMs of color. ResultsThe REDUCE study was approved by the Institutional Review Board of New York University, and recruitment and enrollment began in the winter of 2021. We expect to complete enrollment by the summer of 2022. The results will be disseminated via social media, journal articles, abstracts, or presentations, as well as to participants, who will be given the opportunity to provide feedback to the researchers. ConclusionsThis optimization trial is designed to test the efficacy, feasibility, and acceptability of implementing an application-based, mindfulness-based intervention to reduce stress from discrimination and improve well-being among young SGMs of color. Evidence from this study will assist in the creation of a sustainable, culturally relevant mobile app–based mindfulness intervention to reduce stress from discrimination among young SGMs of color. Trial RegistrationClinicaltrials.gov NCT05131360; https://clinicaltrials.gov/ct2/show/NCT05131360 International Registered Report Identifier (IRRID)DERR1-10.2196/35593

A pattern reconfigurable dielectric resonator antenna emitting at 3.1 GHz is presented in this study. The beam can be steered at 6 degrees, 8 degrees, 14 degrees, and 171 degrees. Three P-i-N diodes are employed in the slots of the ground plane to help steer the beam direction. By changing the state of the three diodes, five states can be obtained. The TE01δ mode is excited using a differential feed technique. Differential feed helps in increasing the gain and reducing the size of the structure. The return loss of each state is less than −25 dB. The gain of the first state is 7.65 dBi, the second and fifth state’s gain is 8.22 dBi, third and fourth state’s gain is 10.6 dBi. This Antenna is designed using Rogers RO4003C material which has low Electrical gravity, low voltage, and high oxidation resistance that makes it appropriate for RF applications. The properties required for RF microwave circuits, matching networks, and controlled impedance transmission lines are present in the RO4003C material. Annealed copper is used for designing the ground plane and feedline which provides excellent conductivity. The antenna is fabricated using the chemical etching process which employs a positive photoresist that gives a higher resolution accuracy for the designed antenna. This process of fabrication has another advantage of inculcating structures from simpler to complex.

Immune-mediated necrotizing myopathy is an uncommon but debilitating disease that can be triggered by drugs, toxins, or cancer. It is similar to polymyositis in presentation but is differentiated by findings on muscle biopsy. We present a case of a 79-year-old male on statin therapy who presented with proximal muscle weakness and elevated creatinine kinase (CK) levels. He had a confirmatory muscle biopsy for immune-mediated necrotizing myopathy. Unfortunately, the patient’s condition eventually escalated, involving respiratory and esophageal muscles in spite of prompt diagnosis and treatment.

Purpose: Retinal toxicity resulting from hydroxychloroquine use manifests photoreceptor loss and disruption of the ellipsoid zone (EZ) reflectivity band detectable on spectral-domain (SD) OCT imaging. This study investigated whether an automatic deep learning-based algorithm can detect and quantitate EZ loss on SD OCT images with an accuracy comparable with that of human annotations. Design: Retrospective analysis of data acquired in a prospective, single-center, case-control study. Participants: Eighty-five patients (168 eyes) who were long-term hydroxychloroquine users (average exposure time, 14 ± 7.2 years). Methods: A mask region-based convolutional neural network (M-RCNN) was implemented and trained on individual OCT B-scans. Scan-by-scan detections were aggregated to produce an en face map of EZ loss per 3-dimensional SD OCT volume image. To improve the accuracy and robustness of the EZ loss map, a dual network architecture was proposed that learns to detect EZ loss in parallel using horizontal (horizontal mask region-based convolutional neural network [M-RCNNH]) and vertical (vertical mask region-based convolutional neural network [M-RCNNV]) B-scans independently. To quantify accuracy, 10-fold cross-validation was performed. Main Outcome Measures: Precision, recall, intersection over union (IOU), F1-score metrics, and measured total EZ loss area were compared against human grader annotations and with the determination of toxicity based on the recommended screening guidelines. Results: The combined projection network demonstrated the best overall performance: precision, 0.90 ± 0.09; recall, 0.88 ± 0.08; and F1 score, 0.89 ± 0.07. The combined model performed superiorly to the M-RCNNH only model (precision, 0.79 ± 0.17; recall, 0.96 ± 0.04; IOU, 0.78 ± 0.15; and F1 score, 0.86 ± 0.12) and M-RCNNV only model (precision, 0.71 ± 0.21; recall, 0.94 ± 0.06; IOU, 0.69 ± 0.21; and F1 score, 0.79 ± 0.16). The accuracy was comparable with the variability of human experts: precision, 0.85 ± 0.09; recall, 0.98 ± 0.01; IOU, 0.82 ± 0.12; and F1 score, 0.91 ± 0.06. Automatically generated en face EZ loss maps provide quantitative SD OCT metrics for accurate toxicity determination combined with other functional testing. Conclusions: The algorithm can provide a fast, objective, automatic method for measuring areas with EZ loss and can serve as a quantitative assistance tool to screen patients for the presence and extent of toxicity.