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Context The percent of underrepresented minority (URM) students who apply to medical school has changed minimally in the past 40 years. Due to the lack of URM applicants, the consequent matriculation of URMs is grossly disproportionate from their percent representation of the US population. Increasing diversity among medical students and physicians has previously been identified as essential to decreasing healthcare disparities among US minorities. Objectives The objective of our study was to recognize the barriers of applying to medical school among URMs in high school. Methods To identify and assess the prevalence of barriers, surveys were distributed to participants of Med-Achieve, a mini-medical school program of diverse high school students in New York City during the 2019–2020 academic year. Results Among students who will be first in their immediate family to attend college, 80.0% perceived a barrier to pursuing medical school. Specified barriers indicated include the cost of medical school (77%), a lack of guidance/role models (53.9%), and the predicted inability to do well in medical school classes (53.9%). At the end of the program, a statistically significant reduction in the barrier of lack of guidance/role models was seen. Conclusions This study highlights the benefit of mini-medical school programs, especially programs with a mentoring component, to decrease the perceived barriers of applying to medical school among URMs. It also suggests the potential role of similar programs to increase diversity in medicine and to decrease healthcare disparities among minorities in the United States.

Introduction Hospital quality improvement and hospital performance are commonly evaluated using parameters such as average length of stay (LOS), patient safety measures and rates of hospital readmission. Thirty-day readmission (30-DR) rates are widely used as a quality indicator and a quantifiable metric for hospitals since patients are often readmitted for the exacerbation of conditions from index admission. The quality of patient education and postdischarge care can influence readmission rates. We report the 30-DR rates of patients with asthma using a national dataset for the year 2013. Objectives The aim of our study was to assess the 30- day readmission (30-DR) rate as well as, the causes and predictors of readmissions. Study designs/methods Using the Nationwide Readmission Database (NRD) (2013), we identified primary discharge diagnoses of asthma by using International Classification of Diseases, Ninth Revision, Clinical Modification code ‘493’. Categorical and continuous variables were assessed by a χ2 test and a Student's t-test, respectively. The independent predictors of unplanned 30-DR were detected by multivariate analysis. We used sampling weights, which are provided in the NRD, to generate the national estimates. Results There were 130 490 (weighted N=311 173) inpatient asthma admissions during 2013. The overall 30-DR for asthma was 11.9%. The associated factors for 30-DR were age 45–84 years (40.32% vs 29.05%; p Conclusions We found that the overall 30-DR rate for asthma was 11.9% all-cause readmission. Major causes of 30-DR were asthma exacerbation (36.74%), chronic obstructive pulmonary disease (11.47%), respiratory failure (6.46%), non-specific pneumonia (6.19%), septicaemia (3.61%) and congestive heart failure (3.32%). One-fourth of the revisits occurred in the first week, while half of the revisits took place in the first 2 weeks. Education regarding illness and the importance of medicine compliance could play a significant role in preventing asthma-related readmission.

Background: It is vital to provide evidence-based research documentation to guide policy decision-making. There is a limited number of studies that participate in dental policy evidence-based research. Case Description: Texas is one of the states with limited dental service coverage for its Medicaid Beneficiaries. The recent senate bill 87R 1152 proposes expansion of dental preventive service to disability status Medicaid Beneficiaries. It is vital to understand how effective the extensive dental service under Medicaid coverage is through evidence-based research. True causal analysis of such public policies by utilizing observational data is only feasible through limited identification strategies. The current paper identifies that. Practical Implication: Through the identified research plan and conceptual framework, it can be established if extensive Medicaid dental service coverages effectively prevent dental disease burden in Texas.

Background Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs. Methods This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis. Results There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20–3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016–2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160–15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529–37.4; P = 0.003). Conclusions Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement.

Objectives This study sought to identify electrocardiographic (ECG) and clinical predictors of sudden cardiac arrest (SCA) in sarcoidosis. Background Sudden cardiac death (SCD) is the leading cause of death in cardiac sarcoidosis (CS) and may be the earliest manifestation of disease. Widespread or repeated advanced imaging is a challenging solution to this problem. ECG is an affordable and widely accessible modality that could help guide diagnostic approaches and risk stratification. Methods Data were obtained from the National Inpatient Sample (2005–2017) using International Classification of Diseases-9th Revision and -10th Revision-Clinical Modification. The primary outcome was to identify predictors of SCA, whereas predictors of SCA in young individuals and those with normal ventricular function served as secondary measures. Furthermore, temporal trends in sarcoidosis as well as SCA were also analyzed. Logistic regression analysis was used to calculate odds ratios, following which a multivariable regression was used to adjust for potential confounders. Results Electrocardiographic markers of AV node dysfunction or bundle branch block are associated with substantially increased risk of SCA in a limited proportion of patients (8.6%). This association is also observed among younger patients ( Conclusions ECG evidence of AV nodal dysfunction or distal conduction disease should raise suspicion for cardiac involvement in patients with sarcoidosis and are associated with increased risk of SCA. ECG markers could help identify patients who would benefit from advanced imaging. The sensitivity of ECGs is, however, limited and presence of a normal ECG does not reflect a low risk of SCA.

BACKGROUND Perianal fistulas account for a substantial discomfort and morbidity to the patient thus affecting productive man hours and quality of life. Accurate pre-operative assessment of course of the primary fistulous track and secondary extension or abscesses is required for successful surgical management of anal fistulas. The purpose of this study was to diagnose and classify pre-operative perianal fistulas. METHODS This is a cross-sectional study at Department of Radiodiagnosis in a tertiary level hospital of southern Rajasthan from November 2018 to November 2020. The study included a total of 50 patients referred to department of radiology for magnetic resonance imaging (MRI). Statistical analysis was done using chi square test and student t test. RESULTS Out of these patients, 56 % were having secondary tract on MRI, 12 % patients were having abscess and 4 % were having horseshoe abscess on MRI. The commonest type of ano-rectal fistula encountered in the study was Grade -II seen in 32 %. CONCLUSIONS MRI is a highly accurate, rapid and non-invasive tool in pre-operative evaluation of the perianal and anal fistulas. MRI evaluation and classification of perianal fistulae has a high degree of diagnostic accuracy. The use of MRI for the diagnosis and classification of perianal fistula can provide reliable information which has both pre-operative and prognostic value. St James University Hospital classification, which is an MR imaging-based grading system for perianal fistula is very useful for effective radiological-surgical communication thus contributing to improved patient care and reduced rate of recurrence. KEYWORDS MR Fistulogram, Perianal Fistula, Anal Fistula, Fistula Classification, Fistulography

Dural arteriovenous fistulas (DAVF) are rare acquired lesions resulting from abnormal shunting between intracranial dural arteries and venous system. Typically arising from structural weakness of the dura and a coinciding trigger factor, DAVFs can present with similar clinical and imaging characteristics to sinus thrombosis. A 61-year-old male with a history of meningioma previously managed with subtotal resection and stereotactic radiosurgery presented with progressive right-sided vision loss and bilateral papilledema. Initial imaging suggested possible sinus occlusion. Catheter angiogram revealed a Borden-Shucart grade III DAVF of the superior sagittal sinus and elevated venous pressures and the patient subsequently underwent endovascular transarterial intervention twice. We report on the first case of a superior sagittal sinus DAVF occurring after surgical resection of a parasagittal meningioma.

This letter presents MAMMOBOT, one of the first millimetre-scale steerable soft growing robots for medical applications. MAMMOBOT aims to access the breast through the nipple and navigate the mammary ducts to detect precursors of invasive breast cancers. Addressing limitations of the state-of-the-art, MAMMOBOT maintains a hollow inner lumen throughout its soft body, enabling the passing of instruments such as miniature endoscopes, biopsy needles, and optical probes for in situ histopathology. MAMMOBOT is developed by a novel manufacturing approach entailing dual LDPE sheet adhesion with localised heat treatment. MAMMOBOT's steerability is achieved through a sub-millimetre profiled tendon-driven catheter that passes through its inner lumen. A duty cycle controller governs steering versus growing to achieve navigation in complex environments within a human-in-the-loop framework. Benchtop experimental evaluation demonstrates the robot's capabilities and agreement with a Reduced-Order Mode (ROM) of its dynamics. Finally, experimental evaluation on a bespoke breast phantom developed for the purposes of this project demonstrates the clinical relevance and potential impact of MAMMOBOT.

Introduction and Objectives: We evaluated patients who underwent treatment for prostate cancer and then subsequent robot-assisted radical cystectomy (RARC). Our objective was to understand clinical...

Background Osteocutaneous fibula free flap (OCFFF) donor sites are often covered with skin grafts, with an additional donor site, more postoperative care, and increased cost. The authors examine posterior tibial artery (PTA) based pedicled propeller flaps (PPF) as an alternative for OCFFF donor site coverage. Patients and methods Retrospective review of 16 consecutive patients from 30 to 79 years old, who underwent OCFFF reconstruction of head and neck defects (11 mandibular, 5 maxillary), with the closure of donor site with PPF based on a perforator from PTA. Mean donor site defect measured 12.9 × 5.1 cm, PPF was an elliptical design, and rotated 180 degrees in a propeller fashion, to cover donor site defect. Visual analog scale (VAS) was used to assess esthetic results, functional outcomes assessed using mobility and range of motion (ROM), and secondary complications including infections, hematomas, and seromas were recorded. Follow-up period was noted in months postoperatively. Other information collected included underlying head and neck pathology. Results Average dimension of PPF measured 13.9 × 4.1 cm. Successful closure of donor site defects in 14 of 16 patients, with two flaps having partial necrosis, one requiring a secondary skin graft. Follow-up was 6 to 10 months, esthetic results with mean VAS 8.8 of 10, full ROM, and mobility noted. No secondary complications were observed. The most common pathology noted was squamous cell carcinoma (6 of 16 patients). Conclusion PPFs based on the soleus branch of the PTA represent an excellent alternative to skin grafts for the closure of OCFFF donor site defects.

Objectives To assess non-invasive imaging for detection and quantification of gland structure, inflammation and function in patients with primary Sjogren's syndrome (pSS) using PET-CT with 11C-Methionine (11C-MET; radiolabelled amino acid), and 18F-fluorodeoxyglucose (18F-FDG; glucose uptake marker), to assess protein synthesis and inflammation, respectively; multiparametric MRI evaluated salivary gland structural and physiological changes. Methods In this imaging/clinical/histology comparative study (GSK study 203818; NCT02899377) patients with pSS and age- and sex-matched healthy volunteers underwent MRI of the salivary glands and 11C-MET PET-CT. Patients also underwent 18F-FDG PET-CT and labial salivary gland biopsies. Clinical and biomarker assessments were performed. Primary endpoints were semi-quantitative parameters of 11C-MET and 18F-FDG uptake in submandibular and parotid salivary glands and quantitative MRI measures of structure and inflammation. Clinical and minor salivary gland histological parameter correlations were explored. Results Twelve patients with pSS and 13 healthy volunteers were included. Lower 11C-MET uptake in parotid, submandibular and lacrimal glands, lower submandibular gland volume, higher MRI fat fraction, and lower pure diffusion in parotid and submandibular glands were observed in patients vs healthy volunteer, consistent with reduced synthetic function. Disease duration correlated positively with fat fraction and negatively with 11C-MET and 18F-FDG uptake, consistent with impaired function, inflammation and fatty replacement over time. Lacrimal gland 11C-MET uptake positively correlated with tear flow in patients, and parotid gland 18F-FDG uptake positively correlated with salivary gland CD20+ B-cell infiltration. Conclusion Molecular imaging and MRI may be useful tools to non-invasively assess loss of glandular function, increased glandular inflammation and fat accumulation in pSS.

Objective The objective of the current study was to evaluate the utility and ease of use of a novel non-invasive tablet-based application for quantification of the pivot shift (QPS) in a multicentre setting. Methods Nine senior orthopaedic surgeons were recruited from academic medical centres and enrolled a total of 90 subjects. All surgeons received video and electronic training on how to perform QPS measurement using a novel tablet-based visual tracking system. Skin markers were used for visual tracking. Each orthopaedic surgeon performed a pivot shift test and obtained a QPS measurement for 10 subjects with known anterior cruciate ligament (ACL) injuries. Anterior translation of the lateral tibial compartment during the reduction event (in millimetre) was recorded. After all subjects were evaluated, the surgeons completed a survey about the ease of use, utility and willingness to use the mobile-based application in clinical practice. All automated visual tracking used to calculate anterior translation of the lateral tibial compartment was manually evaluated to ensure accurate tracking of skin markers. Statistical comparison was made between groups using Student's t-test with significance defined as p Results The results showed that there is adequate tracking of skin markers to provide a QPS measurement across multiple academic medical centres and surgeons in only 70% of subjects. In 27 of 90 subjects, there were tracking errors which resulted in an invalid QPS measurement. Tracking errors were due to background noise, including objects in the room which were the same colour as the skin markers or use of skin preparation solution similar in colour to the skin markers. The QPS measurement was 3.2±1.8 mm, 2.4±1.3 mm in isolated ACL deficiency, and 3.2±2.0 mm with combined ACL and meniscus injury (not significant). There was significant variation among the QPS measurements of different surgeons (p=0.008). Conclusion This study showed that mobile-based QPS measurement software can be used intraoperatively to allow surgeons greater objective feedback regarding the rotatory laxity of the knee prior to and following ACL reconstruction. Software upgrades with improved real-time feedback could help prevent errors in measurement and improve utility of QPS for assessment of injury severity in subjects. Level of evidence Level III.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by recurrent thunderclap headaches associated with segmental vasoconstriction of cerebral arteries, which may result in intracranial hemorrhage (ICH). There is a lack of contemporary data available regarding the ICH burden in RCVS cohort. Our aim of the study is to assess the ICH burden, associated risk factors, and discharge outcome of ICH in patients with RCVS.All patients diagnosed with RCVS in the 2016 Nationwide Readmission Database were identified using ICD-10 code after excluding patients with the concurrent diagnosis of primary angiitis. ICH was defined as both intraparenchymal (IPH), subarachnoid hemorrhage (SAH), and subdural hematoma (SDH). Categorical and continuous variables were assessed by the Rao-Scott Chi-square test and the Wilcoxon signed-rank sum test respectively. We used a multivariable survey-weighted logistic model to determine the association between ICH and RCVS patient-level characteristics.A total of 799 patients were identified with RCVS. Total hospitalization of ICH was 43.4% [(95% CI 36.4-50.4%); (n = 346)] including SAH 35.9% [(95% CI 29.7-42.1%); (n = 287)], IPH 13.1% [(95% CI 9.5-16.7%); (n = 105)] and SDH 3.6% [(95% CI 1.5-5.6%); (n = 28)]. Patients with hemorrhagic RCVS (H-RCVS) had a mean age (years ± SE) of 47.4 ± 1.1 vs. 45.5 ± 1.2 years in R-RCVS (p = 0.247); and were predominantly female (84.0% vs. 68.8%; p = 0.001); with longer inpatient stays (10.9 vs. 6.8 days; p = 0.016); and a higher inpatient cost ($44,300 vs. $21,350; p 0.001). On multivariable analyses, higher odds of ICH were female sex 2.57 (95% CI 1.45-4.55; p = 0.001), middle age-group (45-64 years) 1.87 (CI: 1.11-3.15; p = 0.018) and older age group ( 64 years) 3.72 (CI: 1.15-12.03; p = 0.029). About 67.0% of all H-RCVS patients were discharged home, with no observed inpatient mortality.Intracerebral hemorrhage is the most common vascular complication in hospitalized RCVS patients, resulting in longer hospitalizations with more invasive procedures and higher healthcare expenditure. However, overall outcomes are excellent regardless of types of ICH, with no inpatient mortality observed in patients with hemorrhagic RCVS. Female sex and middle to older age-group are associated with higher odds of ICH.

Purpose Tracking cells in vivo using imaging can provide non-invasive information to understand the pharmacology, efficacy, and safety of novel cell therapies. Zirconium-89 (t1/2 = 78.4 h) has recently been used to synthesize [89Zr]Zr(oxinate)4 for cell tracking using positron emission tomography (PET). This work presents an in vitro approach to estimate the detection limit for in vivo PET imaging of Jurkat T cells directly labeled with [89Zr]Zr(oxinate)4 utilizing clinical PET/CT and PET/MRI. Methods Jurkat T cells were labeled with varying concentrations of [89Zr]Zr(oxinate)4 to generate different cell-specific activities (0.43–31.91 kBq/106 cells). Different concentrations of labeled cell suspensions (104, 105, and 106 cells) were seeded on 6-well plates and into a 3 × 3 cubic-well plate with 1 cm3 cubic wells as a gel matrix. Plates were imaged on clinical PET/CT and PET/MRI scanners for 30 min. The total activity in each well was determined by drawing volumes of interest over each well on PET images. The total cell-associated activity was measured using a well counter and correlated with imaging data. Simulations for non-specific signal were performed to model the effect of non-specific radioactivity on detection. Results Using this in vitro model, the lowest cell number that could be visualized on 6-well plate images was 6.8 × 104, when the specific activity was 27.8 kBq/106 cells. For the 3 × 3 cubic-well, a plate of 3.3 × 104 cells could be detected on images with a specific activity of 15.4 kBq/106 cells. Conclusion The results show the feasibility of detecting [89Zr]Zr(oxinate)4-labeled Jurkat T cells on clinical PET systems. The results provide a best-case scenario, as in vivo detection using PET/CT or PET/MRI will be affected by cell number, specific activity per cell, the density of cells within the target volume, and non-specific signal. This work has important implications for cell labeling studies in patients, particularly when using radiosensitive cells (e.g., T cells), which require detection of low cell numbers while minimizing radiation dose per cell.

Purpose\ud\udEarly and accurate localization of lesions in patients with biochemical recurrence (BCR) of prostate cancer may guide salvage therapy decisions. The present study, 18F-Fluciclovine PET/CT in biochemicAL reCurrence Of Prostate caNcer (FALCON; NCT02578940), aimed to evaluate the effect of 18F-fluciclovine on management of men with BCR of prostate cancer.\udMethods and Materials\ud\udMen with a first episode of BCR after curative-intent primary therapy were enrolled at 6 UK sites. Patients underwent 18F-fluciclovine positron emission tomography/computed tomography (PET/CT) according to standardized procedures. Clinicians documented management plans before and after scanning, recording changes to treatment modality as major and changes within a modality as other. The primary outcome measure was record of a revised management plan postscan. Secondary endpoints were evaluation of optimal prostate specific antigen (PSA) threshold for detection, salvage treatment outcome assessment based on 18F-fluciclovine-involvement, and safety.\udResults\ud\ud18F-Fluciclovine was well tolerated in the 104 scanned patients (median PSA = 0.79 ng/mL). Lesions were detected in 58 out of 104 (56%) patients. Detection was broadly proportional to PSA level; ≤1 ng/mL, 1 out of 3 of scans were positive, and 93% scans were positive at PSA >2.0 ng/mL. Sixty-six (64%) patients had a postscan management change (80% after a positive result). Major changes (43 out of 66; 65%) were salvage or systemic therapy to watchful waiting (16 out of 66; 24%); salvage therapy to systemic therapy (16 out of 66; 24%); and alternative changes to treatment modality (11 out of 66, 17%). The remaining 23 out of 66 (35%) management changes were modifications of the prescan plan: most (22 out of 66; 33%) were adjustments to planned brachytherapy/radiation therapy to include a 18F-fluciclovine-guided boost. Where 18F-fluciclovine guided salvage therapy, the PSA response rate was higher than when 18F-fluciclovine was not involved (15 out of 17 [88%] vs 28 out of 39 [72%]).\udConclusions\ud\ud18F-Fluciclovine PET/CT located recurrence in the majority of men with BCR, frequently resulting in major management plan changes. Incorporating 18F-fluciclovine PET/CT into treatment planning may optimize targeting of recurrence sites and avoid futile salvage therapy.

Aim: To analyse the functional outcome of Medial malleoli after Internal Fixation of medial malleolar fracture with fully threaded 4 mm cancellous cannulated screws. Introduction: Ankle fractures are one of the commonest fractures encountered by an orthopaedic surgeon with the majority being treated with open reduction and tension band wiring but it has a midterm and long term complications like hardware prominence, low-grade infection and hardware removal. Purpose of this study on medial malleolus fracture is to evaluate functional outcome after open reduction and fully threaded 4 mm cancellous cannulated screw fixation which has a very low complication rate. Materials and Method: This is a prospective study done in c u shah medical college and hospital Surendranagar. In the present study 30 cases of bimalleolar ankle fracture.Common Mechanism of Injury was Road traffic accidents and fall from height. the diagnosis was confirmed by Anteroposterior, lateral and Mortise radiograph. Classifications used are Lauge-Hanse Classification and DenisWeber Classification. Fully threaded 4 mm Cannulated cancellous screw was used for medial malleolus fixation.The anatomical plate used for fibula fixation. Post-op protocol: Postoperatively limb were immobilized in a plaster splint for 6 weeks and limb were elevated. Results: According to Baird and Jackson scoring system out of 30 cases, 56.67% were excellent and 26.67% were good, 13.34% were fair and 3.32% were poor. Conclusion: Open reduction and tension band wiring fixation of medial malleolus has biomechanically proved stable fixation but it has a midterm and long term complications like hardware prominence, low-grade infection and hardware removal. The current study has studied that open reduction and fully threaded 4 mm cancellous cannulated screw in medial malleolus fracture have a comparable functional outcome with a low complication rate.

Fetal hepatomegaly is associated with significant fetal morbidity and mortality. However, hepatomegaly might be overlooked when numerous other fetal anomalies are present, or it might not be noticed when it is an isolated entity. As the largest solid organ in the abdomen, the liver can be seen well with US or MRI, and the normal imaging characteristics are well described. The length of the fetal liver, which can be used to identify hepatomegaly, can be determined by measuring the liver from the diaphragm to the tip of the right lobe in the sagittal plane. Fetal hepatomegaly is seen with infection, transient abnormal myelopoiesis, liver storage and deposition diseases, some syndromes, large liver tumors, biliary atresia, and anemia. Some of these diagnoses are treatable during the fetal period. Attention to the associated findings and specific hepatic and nonhepatic imaging characteristics can help facilitate more accurate diagnoses and appropriate patient counseling.©RSNA, 2020.

Background: Post renal transplant UTI is very common, increasing the morbidity and mortality with high chances of graft failure. Majority of centres use prophylactic antibioitcs like TMP-SMX after renal transplantation within first 6 months. Aims and Objectives: To understand the incidence of UTI and it's risk factors, to compare the effectiveness of using individual commode in decreasing incidence of post transplant UTI with historical cohort of renal transplant recipients. Materials and Methods: 25 patients were recruited from April 01, 2017, to June 01, 2017. They were encouraged to bring along a portable commode to use it during their stay as well as at home after discharge and followed for 1 month for presence of urinary tract infection. Results: 6 patients had culture proven UTI(24%) in historical cohort while no patient had UTI in study group using commode(0%). Conclusion: Individualizing personal waste disposal techniques using disposable bedside commode is an effective and economical strategy.

Injuries of the posterior cruciate ligament (PCL) are, compared to other knee injuries, quite rare. They account for around 3% of all acute traumatic knee injuries. The underlying mechanism leading to a PCL injury is a posterior directed force onto the anterior proximal tibia causing posterior tibial translation. This occurs normally during high-velocity collisions as a “dashboard” injury as well as in competitive athletic sports such as football. Similar to the anterior cruciate ligament (ACL), the PCL consist of two bundles (anterolateral and posteromedial) and is designed to prevent posterior translation of the tibia. The tension on the PCL differs according to the flexion angle of the knee. The diagnosis of PCL injuries is based on a careful clinical examination and radiological analysis. The radiological analysis consists of several X-rays with and without force loaded to the anterior proximal tibia, as well as an MRI which is considered the gold standard. CT scans can be performed to analyze for possible bony injuries. The treatment options include nonoperative treatment for isolated, partial PCL injuries and operative reconstruction for high-grade isolated PCL injuries or multiligamentous knee injuries. The surgical approach can be either open or arthroscopic, and similar to ACL reconstruction, a single or double bundle approach can be performed. Regarding the literature, there is no clear evidence for either double or single bundle reconstruction. Various PCL reconstruction techniques exist, including transtibial tunnel or a tibial-inlay technique. Common complications in PCL reconstruction include persistent posterior laxity and injury to the popliteal artery, the neurovascular structures, and meniscal roots during tunnel reaming. The postoperative treatment protocol includes restriction to 90° of flexion for the first 2 weeks with weight bearing as tolerated and the knee locked in extension, followed by free range of motion in a brace with weight bearing as tolerated. Physical therapy should focus on quadriceps muscle strengthening. Return to sports following PCL reconstruction should be delayed until 9–12 months from surgery.

Objectives: Irreparable rotator cuff tears can be challenging to manage in younger patients who are not well indicated for reverse total shoulder replacement. Treatment options in this patient population include both marginal convergence (MC) and superior capsular reconstruction (SCR). While both treatment options have demonstrated good short term outcomes, they have vastly different associated costs and operative times. Thus, the purpose of this study was to compare range of motion (ROM), patient reported outcomes, and re-operation rates following MC and SCR. We hypothesized that SCR would outperform MC regarding functional and subjective outcomes. Methods: A retrospective review was conducted on 44 patients from two surgeons with irreparable rotator cuff tears that underwent either MC (28 patients, 28 shoulders) or SCR (16 patients, 16 shoulders) from 2014-2019 at a single academic center. Patient inclusion criteria were the following: failed conservative or prior surgical management, no or mild glenohumeral arthritis, Goutallier grade 3 or 4 fatty infiltration of the involved muscles, Hamada grade 1 or 2 rotator cuff arthropathy, intact or repairable subscapularis tear and minimum of 1 year follow-up. Visual Analogue Scale (VAS) for pain, active forward flexion (FF) and external rotation (ER) range of motion, reoperation rate, and rate of conversion to reverse total shoulder arthroplasty were evaluated. For statistical analysis, t-tests were used to determine differences in functional outcomes and VAS, while Chi-Squared tests were used to determine differences in the rate of re-operation and conversion to arthroplasty (*p < 0.05). Results: The mean age at the time of surgery for the MC and SCR groups was 64.4 and 58.5 years, respectively, with an average follow-up of 31.5 months for the MC group and 17.8 months for the SCR group. There were no significant differences in the mean age at the time of surgery, gender, body mass index, pre-operative FF and ER, and pre-operative VAS between the groups. The MC group did not have a significant improvement FF with a mean pre-operative FF of 144.4°(range: 30-170°) and post-operative FF of 150.5°(range: 90-180). The same was true for the SCR group, with a mean pre-operative FF 127.5°(range: 40-170°) and post-operative FF of 146.3°(range: 40-170). There was also no significant improvement in ER post-operatively in either group. Both the MC and SCR group had significant improvements in VAS for pain from an average of 7.3 (range: 1-10) pre-operatively to 2.5 (range: 0-10) post-operative for the MC group (p < 0.01) and from 7.3 (range: 3-10) pre-operatively to 1 (range: 0-4) post-operative for the SCR group (p < 0.01). There were no significant differences in the post-operative FF or ER, change in FF or ER, post-operative VAS, or change in VAS between the two treatment groups. The rate of conversion to arthroplasty was not significantly different between the groups at 3.6% for the MC group and 12.5% for the SCR group. Additionally, the overall reoperation rate was not significantly different between the MR and SCR groups at 10.7% and 12.5%, respectively. Conclusions: There were no significant differences between the MC and SCR treatment groups. While both MC and SCR were effective in improving VAS for pain, neither treatment consistently resulted in significant improvement in ROM. Further studies with long term outcomes are needed to determine if there are certain indications for which one treatment results in better outcomes.

Objectives: While rotator cuff tears often require repair of the supraspinatus, patients can also have a concurrent tear of the subscapularis requiring repair. Previous smaller studies have shown good clinical outcomes following the repair of the subscapularis and rotator cuff during the same procedure.1 The purpose of this study was to compare clinical outcome measures between patients who had isolated supraspinatus repairs versus those who had a supraspinatus tear with a concurrent subscapularis repair. Methods: A retrospective review of 166 patients who underwent arthroscopic supraspinatus repair with or without a concurrent subscapularis repair between 2013-2018 with a minimum of one-year follow up was performed. Patients were separated into two groups based on their treatment: 100 had an isolated supraspinatus repair (SP) and 66 had both a supraspinatus and subscapularis repair (SB). The primary outcome was revision rotator cuff repair. Secondary outcomes were objective measures such as range of motion (ROM) and strength testing, including flexion (FF), external rotation (ER), and internal rotation (IR), as well as patient-reported outcome measures (PROs) including visual analog pain scale (VAS) and subjective shoulder value (SSV). Outcomes were compared using the Mann- Whitney Test and Fisher’s Exact Test with pResults: There was no significant difference in the rate of revision surgery required following isolated supraspinatus repair versus those with a subscapularis repair. Additionally, there were no significant differences between groups for all PROs, all ROM parameters, and all strength parameters (all p > 0.05) (Table 1). Conclusions: The data from this study demonstrated that patients who require a subscapularis repair at the time of their rotator cuff repair can expect similar short term outcomes to those patients who only required repair of their supraspinatus.

Introduction: The temporal bone is a complex anatomic structure that contains the organs of hearing and balance and has direct contact with brainstem, cerebellum and temporal lobe of brain. Radiographic assessment of temporal bone is difficult owing to complicated anatomical structure of middle and inner ear. High resolution computed tomography (HRCT) - a modification of routine CT produces images with higher contrast and a better spatial resolution. HRCT has the advantage of topographic visualization, devoid of artifacts from superimposition of structures. It provides information not only about bony outline but also soft tissue changes making it possible for the accurate assessment of pathology prior to surgical exploration regarding location, extent and complication of the disease. Material and methods: This was a cross sectional study of 50 patients who were clinically suspected of having symptoms related to the temporal bone like hearing loss, otorrhea, otalgia, tinnitus, vertigo, ear bleed, cranial nerve palsies, fever, ataxia etc were referred and subjected to HRCT of the temporal bone at Geetanjali Medical College and Hospital (Udaipur) between Nov 2017 and June 2019. Results: CSOM and Cholesteatoma were the most common diseases found by HRCT and Intra-op/Follow-up scan followed by Fractures, acoustic neuroma, Glomus tympanicum and Atretic EAC. Almost all the lesions were correctly detected by HRCT when confirmed with Intra-op/follow up findings. Conclusion: HRCT can very accurately detect Temporal bone pathology. Keywords: HRCT, CSOM, CT

Aim Adrenocortical cancer (ACC) is an aggressive malignancy and robust prognostic factors remain unclear. The presence of sarcopenia has been shown to negatively impact survival for other malignancies, but has not been extensively analyzed in ACC. Methods Patients who underwent resection of their ACC between 2010 and 2020 were identified; therapeutic, operative, and outcome data were analyzed. Sarcopenia was assessed by calculation of the skeletal muscle index (SMI) and was defined as an SMI Results Data on 35 patients (18 F: 17 M; median age 54 [range: 18-86]) who had primary surgical treatment were analyzed. Median tumor size was 10 cm [range:3-15]. In eleven patients (31%), the tumor was hormonally active (cortisol = 8;23%). Seventeen patients (49%) were classified as having sarcopenia on their pre-operative CT scan. The Intraclass Correlation Coefficient (ICC) for intra- and inter-observer variability showed very good agreement (0.99 and 0.98). There was no difference in incidence of sarcopenia stratifying for sex, BMI, or tumor-size, but incidence was higher with increasing age (p Conclusion The presence of sarcopenia in patients undergoing surgery for ACC could be a predictor of reduced overall survival, although replications of these analyses should be performed in similar, larger cohorts. Specifically, the influence of a patient's hormonal status on the manifestation of sarcopenia should be further defined.

We report the case of a 66-year-old previously healthy man presenting with blood and mucus in his urine. Cystoscopy revealed a mass in the prostatic urethra, and endoscopic biopsy showed adenocarcinoma in situ with mucinous features. Endorectal multiparametric prostate MRI demonstrated a 1.9 cm T2 hyperintense mass in the peripheral zone of the left prostatic apex with extension into the urethral lumen. No diffusion restriction or early enhancement was seen in the mass. Radical prostatectomy was performed, and final pathology demonstrated a mucin-producing urothelial adenocarcinoma arising from the prostatic urethra. The peripheral zone T2 hyperintense abnormality correlated with abundant pools of mucin extending into the prostatic stroma and surrounded by neoplastic prostatic glandular cells. We conclude prostatic urethral mucinous urothelial carcinoma should be included in the differential diagnosis for T2 hyperintense prostatic masses.

A 56-year-old female with a history of meningioma status post subtotal resection (Simpson grade IV) and extensive radiation therapy presented with osteoradionecrosis (O.R.N.) managed previously with a microvascular free flap (MVFF). The evaluation revealed worsening O.R.N. and a scalp defect of 15 × 10 cm. The patient underwent MVFF reconstruction utilizing a free latissimus muscle flap covered by meshed split-thickness skin graft (STSG). Her surgery was complicated by delayed free flap failure and Serratia marcescens growth, which occurred sometime after discharge from the hospital. This was managed with removal of the free muscle flap and skin graft, serial debridement's, antibiotics, and replacements of a synthetic dural matrix and negative pressure wound therapy (NPWT). Once a clean wound bed was again obtained, the patient underwent fasciocutaneous anterolateral thigh (A.L.T.) MVFF reconstruction, which was complicated by left hypoglossal nerve injury, dehiscence of the flap inset, and dehiscence of the neck access incision requiring revision surgery. On the last follow-up 2 weeks after her surgery, the patient had 100% flap viability and a 2 × 1.5 cm on the left parietal aspect of the flap healing be secondary intent. We demonstrate that NPWT is successful in managing open calvarial wounds due to O.R.N.

Introduction Acute symptomatic seizures (ASS) are seen in one-third of cerebral venous sinus thrombosis (CVT) cases either as the presenting symptom or shortly after diagnosis in the acute phase. The goal of our study was to assess the trends in recognition of ASS in CVT over the years and to determine factors predictive of ASS in the patients with CVT for early identification of candidates who would benefit from anti-seizure medications (ASM). Materials and methods The Nationwide Inpatient Sample (NIS) database was accessed to identify adult inpatient admissions with a primary or secondary diagnosis of CVT. Comorbidities, complications, risk factors, and procedures pertaining to these hospitalizations were compared between CVT patients with and without ASS. Results A total of 53,710 CVT-related hospitalizations were identified, of which 18.1% of patients had a burden of ASS at presentation or subsequently during hospitalization. CVT patients with ASS had a longer average duration of hospitalization and higher overall morbidity and mortality. Conclusions Our study showed ~one in five patients (18.1%) with CVT had ASS. ASS patients had higher odds of mortality and disability at discharge, requiring post-discharge rehabilitation care. It is crucial to identify risk factors of ASS in the CVT population to avoid future preventable revisit related to seizures. Additional research is required for risk stratification of patients with CVT for primary and secondary seizure prophylaxis and determining the appropriate choice and duration of ASM in these patients.

Bicuspid aortic valve (BAV) is one of the most common inherited valvular anomalies, occurring either in isolation or as a part of other congenital syndromes. It is found in approximately 1% of the ...

Introduction: The widespread use of diagnostic and therapeutic ionizing radiation raises concerns regarding excessive occupational and patient exposure. In this study, we test a novel fluo...

Upper gastrointestinal hemorrhage (UGIH) and lower gastrointestinal hemorrhage (LGIH) are 2 of the most common reasons for hospital admissions across the United States. The 30-day readmission after index admission poses a major burden on the health care infrastructure, and thus, it is important to assess the causes of 30-day readmission for patients with UGIH and LGIH.The study cohort was derived from the 2013 National Readmission Database. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Volume 3 diagnosis codes were utilized to identify UGIH and LGIH patients from this data set. Patients who were readmitted to the hospital within 30 days within the same calendar year were further analyzed. Categorical variables and continuous variables were assessed by the χ test and the student t test, respectively. The independent predictors of unplanned 30-day readmissions were recognized by multivariate logistic regression, adjusting for stratified cluster design of National Readmission Database. SAS 9.4 (SAS Institute Inc., Cary, NC) was used for data analysis.The number of index admissions identified from the National Readmission Data 2013 were 82,290 for UGIH and 133,114 for LGIH. All-cause 30-day readmission rate for UGIH versus LGIH was 14.6% (readmitted N=12,046; 56.64% age 65 y and above) versus 14.4% (readmitted N=19,128; 70.21% age 65 y and above and 49.61% men). Gastrointestinal causes were most common (33.9% vs. 39.6%), followed by cardiac (13.3% vs. 15.3%), infectious (10.4% vs. 9.1%), and respiratory causes (7.8% vs. 7.1%) for 30-day readmission for UGIH and LGIH. Significant predictors of increased 30-day readmission (odds ratio, 95% confidence interval, P-value) included metastatic disease (2.15, 1.75-2.64, P0.001), discharge against medical advice (1.85, 1.55-2.22, P0.001), and length of stay3 days (1.50, 1.38-1.63, P0.001). Predictors for 30-day readmission for LGIH included metastatic disease (1.75, 1.48-2.06, P0.001), liver disease (1.59, 1.49-1.71, P0.001), and drug abuse (1.38, 1.21-1.58, P0.001).Most common reason for UGIH and LGIH readmission was related to gastrointestinal disease, followed by cardiac, infectious, and respiratory etiologies. By addressing these etiologies for readmission, it may be possible to reduce adverse outcomes.

Objective Time-sensitive communication of critical imaging findings like pneumothorax or pulmonary embolism to referring physicians is essential for patient safety. The definitive communication is the radiology free-text report. Quality assurance initiatives require that institutions audit these communications, a time-intensive manual task. We propose using a rule-based natural language processing system to improve the process for auditing critical findings communications. Methods We present a pilot assessment of the feasibility of using an automated critical finding identification system to assist quality assurance teams’ evaluation of critical findings communication compliance. Our assessment is based on chest imaging reports. Critical findings are identified in radiology reports using pyConTextNLP, an open source Python implementation of the ConText algorithm. Results In our test set, there were 75 reports with critical findings and 591 reports without critical findings. pyConTextNLP correctly identified 69 of the positive cases with 8 false-positives for a sensitivity of 0.92 and a specificity of 0.99. Discussion Natural language processing can provide valuable assistance to auditing critical findings communications.

Background Hospital readmission rate is an important indicator of the quality of care, healthcare economic burden, and post-discharge care. Multiple sclerosis (MS) is a potentially progressive neurological disease predominantly affecting young women. The natural history of the disease involves intermittent relapses and/or accrued baseline disability overtime especially in older patients contributing to frequent hospitalizations. The readmission metrics for patients with MS have not been studied. Objective To estimate nationwide 30-day readmission (30-DR) rate among patients hospitalized with MS and to study the predictors of readmission based on age and gender. Methods This was a retrospective observational cohort study of patients hospitalized with primary discharge diagnosis of MS using 2013 Nationwide Readmission Database (NRD). The cases were identified by ICD 9-CM code (340) linked to MS diagnosis. We used patient unique identifiers 'NRD visit link' to identify MS index hospitalizations and readmissions. Age ( 40 years) and gender-based analyses were performed using multivariable logistic regression adjusting co-variables to identify the patient/system-specific factors associated with 30-DR. Results The overall 30-day readmission rate (30-DRR) was 10.2%. No gender difference was seen in the readmission rates (men 10.7% vs. women 10.1%, p = 0.56); higher readmission rates were observed in older patients (11.2% vs. 8.8%; p = 0.0055). However, readmission cost was higher in younger age group (≈ $ 12,586 vs. ≈$ 11,827; p = 0.62) and among women (≈$ 12,217 vs. ≈$ 11,746; p = 0.75). The common causes of 30-DR were MS exacerbation (42.5%), sepsis (13.7%) and respiratory complications (7.3%). The predictors of higher 30-DRR in younger patients were diabetes (OR 1.87, p = 0.02), intravenous immunoglobulin (IVIG) use (OR 3.64, p = 0.016), and discharge to a nursing facility (OR 1.66, p = 0.03), whereas in older age group, higher Charlson-Deyo Comorbidity Index (CCI) (OR 1.15, p = 0.0057), and plasma exchange (PLEX) (OR 2.38, p = 0.03) were predictive of higher readmission rate. The longer length of stay (LOS) during index admission (OR 1.81, p = 0.03) in men and higher CCI (OR 1.15, p = 0.007) and intravenous immunoglobulin (IVIG) use (OR 2.27, p = 0.04) in women increased the odds of readmission. Conclusion The overall 30-day readmission rate among patients following hospitalization for MS was 10.2%. The readmission rate was higher in older (>40 years) patients. The common causes of readmission were MS exacerbation, respiratory complications, and sepsis. A higher systemic disease burden, longer length of stay, and treatment with IVIG and PLEX were associated with higher risk of readmission. The readmissions were associated with higher cost of care and longer LOS compared to index admissions highlighting the economic impact of readmissions. Future strategies to lower the risk of readmissions in patients with MS should focus on optimal management of medical co-morbidities and infections.

Purpose To determine the effect of knee flexion angle during graft fixation on outcomes and complications following medial patellofemoral ligament (MPFL) reconstruction. Methods Three databases (PubMed, EMBASE, and MEDLINE) were searched from database inception to January 2018. After screening based on inclusion and exclusion criteria, patient demographics, fixation technique, graft selection, outcomes, and complications were extracted from the included studies. The studies were grouped based on flexion angle used during graft fixation: low (0°-30°) and high (45°-90°) flexion angle group. Methodological Index for Non-Randomized Studies criteria were used to assess the quality of each included study. Descriptive statistics are presented. Results Seventeen studies (of 3,399) were included and were either cohort (n = 1) or case series (n = 17) study designs. A total of 556 patients with a mean age of 23.6 years (range, 10-60 years) underwent MPFL reconstructions, with 458 patients in the 0° to 30° fixation group and 98 in the 45° to 90° fixation group. The mean Kujala score improved from 45 to 72.9 (365 patients) preoperatively to 83 to 94.5 (460 patients) postoperatively for the 0° to 30° fixation group and from 53.3 to 72 preoperatively to 92.2 to 95.2 postoperatively for the 45° to 90° fixation group (98 patients). Conclusions The knee flexion angle during MPFL graft fixation ranges from 20° to 90°. Graft fixation at low and high knee flexion angles during MPFL reconstruction showed excellent patient-reported outcomes and low patellar redislocation rates overall, with no clear differences between the 2 groups based on the currently available data. Level of Evidence Level IV, systematic review of Level III-IV studies.

Diffusion tensor imaging (DTI) studies show widespread white matter abnormalities in schizophrenia, but it is difficult to directly relate these parameters to biological processes. Neurite orientation dispersion and density imaging (NODDI) is geared toward biophysical characterization of white matter microstructure, but only few studies have leveraged this technique to study white matter alterations. We recruited 42 schizophrenia patients (30 antipsychotic-naïve and 12 currently untreated) and 42 matched controls in this prospective study. We assessed the orientation dispersion index (ODI) and extracellular free water (FW) using single-shell DTI data before and after a 6-week trial of risperidone. Longitudinal data were available for 27 patients. Voxelwise analyses showed significantly increased ODI in the posterior limb of the internal capsule in unmedicated patients (242 voxels; x = −24; y = 6; z = 6; p

Clinicians have different techniques and varying levels of experience with the pivot shift test, introducing variability into its performance. The purpose of this study was to evaluate the influence of teaching and repetition on the success rate and anterior translation of the lateral knee compartment during the pivot shift test in a cadaveric ACL injury model. Twenty-five participants (five each of medical students, orthopaedic surgery residents, physical therapists, athletic trainers, sports medicine fellows) were recruited and a senior orthopaedic surgeon served as gold standard examiner. Each participant performed 20 pivot shift tests on lower extremity cadaveric specimens with ACL deficiency and lateral meniscectomy: 5 prior to education (baseline), 10 after watching an instructional video (passive teaching), and 5 after an interactive education session (active teaching). The anterior translation of the lateral knee compartment was recorded during each pivot shift test using electromagnetic tracking system. For medical students and orthopaedic surgery residents, significant improvement in success rate was found when compared to baseline (12% and 24%, respectively) after both passive (36% and 60%, respectively) and active teaching (52% and 72%, respectively) (p

Background: In anterior cruciate ligament–deficient (ACL-D) knees, injury pattern and bony morphologic features have been shown to influence both static anterior tibial subluxation relative to the femur and dynamic rotatory knee laxity. Therefore, the relationship between static anterior tibial subluxation and dynamic rotatory knee laxity was investigated. Purpose: To determine whether static tibial subluxation as measured on magnetic resonance imaging (MRI) is associated with the grade of rotatory knee laxity in ACL-D knees. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Two-hundred fifty-eight knees underwent preoperative, image-guided assessment of lateral knee compartment translation during quantitative pivot shift (QPS). Subluxations of the medial and lateral tibial plateaus were measured on preoperative MRI in a subset of primary ACL-D knees meeting criteria for high-grade (QPS > 5.2 mm) and low-grade (QPS < 2.4 mm) rotatory laxity. Tibial subluxations on MRI were compared between patients with high- and low-grade rotatory laxity through use of pairwise t test and were analyzed via univariate and multivariate logistic regression. Significance was set at P < .05. Results: On MRI, greater anterior subluxation of the lateral tibial plateau was observed in patients with high-grade compared with low-grade rotatory knee laxity (4.5 mm vs 2.3 mm; P < .05). No similar relationship was observed for the medial tibial plateau (−0.9 mm vs −0.4 mm; P > .05). Univariate logistic regression demonstrated that static subluxation of the lateral tibial plateau was associated with high-grade rotatory knee laxity (odds ratio [OR], 1.2; P < .05). An optimal cutoff of 2.95 mm of static lateral tibial subluxation was associated with high-grade rotatory knee laxity (sensitivity, 75%; specificity, 63%). Lateral meniscal injury was the first variable entered into a multivariate regression analysis and proved to be most associated with high-grade rotatory knee laxity (OR, 6.8; P < .05). When lateral meniscal injury was excluded from multivariate regression analysis, static anterior subluxation of the lateral tibial plateau alone was associated with high-grade rotatory knee laxity (OR, 1.2; P < .05). Conclusion: Data from this MRI study of two distinct rotatory knee laxity groups showed that static anterior subluxation of the lateral tibial plateau of 2.95 mm or greater was associated with high-grade rotatory knee laxity, and each millimeter increase of lateral tibial plateau subluxation was associated with a 1.2-fold odds of high-grade rotatory knee laxity. Anterior subluxation of the lateral tibial plateau on MRI was not independently associated with high-grade rotatory knee laxity in the presence of concomitant lateral meniscal injury. Static measurements made preoperatively may aid in predicting high-grade rotatory knee laxity and refining the indications for individualized knee surgery.

Objective Incomplete resection of neocortical epileptogenic foci correlates with failed epilepsy surgery in children. We often treat patients with neocortical epilepsy with a staged approach using invasive monitoring to localize the focus, resect the seizure onset zone, and, in select cases, post-resection invasive monitoring (PRM). We report the technique and the outcomes of children treated with staged surgery including PRM. Methods We retrospectively reviewed the charts of pediatric patients with neocortical epilepsy who underwent resective surgery with PRM. Results We identified 71 patients, 5 patients with MRI-negative epilepsy and 66 patients with MRI-identified neocortical lesions; 64/66 (97%) patients had complete lesionectomy. In 61/71 (86%) patients PRM was associated with positive outcomes. Those findings were: 1) clinical seizures with electrographic involvement at resection margins (47%); 2) subclinical seizures and interictal discharges at resection margins (29%); and 3) clinical and subclinical seizures revealing a new epileptogenic focus (20%). In 55/71 (77%) patients, PRM data led to additional resection (re-resection; RR). Six additional patients had no further resection due to overlap with eloquent cortex. Histopathology showed tuberous sclerosis complex (TSC; n = 46), focal cortical dysplasia (FCD; n = 16)), gliosis (n = 4), tumors (n = 4), and Sturge-Weber syndrome (n = 1). There were no major complications. Seizure-free outcome in children with TSC was 63% at 1-year follow-up and 56% at 2-year follow-up. In FCD, seizure freedom after 1 and 2 years was 85%. Significance Post-resection monitoring may provide additional information about the extent of the epileptogenic zone, such as residual epileptogenic activity at the margins of the resection cavity, and may unmask additional seizure foci. This method may be especially useful in achieving long-term stable seizure-free outcome.

Background The ulnar collateral ligament (UCL) of the elbow is commonly injured in overhead athletes, especially baseball pitchers. UCL reconstruction has shown good outcomes regarding return to play, but revision rates are on the rise. This review was conducted to determine the effect of elbow flexion angle during graft fixation on outcomes and complications after UCL reconstruction. Methods MEDLINE, Embase, and PubMed were searched from database inception to November 16, 2017. Patient demographics, surgical technique, graft selection, outcomes, and complications were extracted from the included studies. The quality of each study was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. Descriptive statistics are presented. Results Six studies, with a total of 1168 patients, were included, and all were case series. Excellent Conway scores were present in 83.8% of patients for the 0° to 30° group and in 91.1% of patients for the 45° to 70° group, with no significant differences in return to play between the groups. The rate of revision UCL reconstruction was significantly higher with graft fixation at 0° to 30° (1.4%) compared with fixation at 45° to 70° (0%; P Conclusions Elbow flexion angle during graft fixation may not influence return to the same or higher level of competition but appears to influence the need for a revision after UCL reconstruction. However, the available current evidence possesses a high degree of fragility, and further studies are needed with objective measurements to determine the optimal elbow flexion angle for graft fixation.

Background and importance Pseudobulbar affect (PBA) is characterized by sudden, uncontrollable laughing, crying, or both in the absence of an appropriate triggering stimuli. Usually due to an underlying neurological condition, PBA has been reported less commonly in traumatic brain injury (TBI) and patients with normal pressure hydrocephalus (NPH). This case documents the successful management of a male patient with PBA and post-traumatic NPH with ventriculoperitoneal shunt placement. Clinical presentation An 88-year-old male initially presenting with acute right subdural hematoma after a fall underwent right decompressive hemicraniectomy and cranioplasty. On 2-month follow-up, the patient was diagnosed with PBA as well as post-traumatic hydrocephalus, confirmed with Center for Neurologic Study – Liability Scale (CNS-LS) questionnaire as well as a cerebrospinal fluid tap test (CSF-TT), respectively. The patient underwent ventriculoperitoneal shunt placement with successful resolution of PBA and post-traumatic NPH. Conclusion A select subset of patients presenting with post-traumatic NPH may demonstrate successful resolution of PBA symptoms following surgical intervention to address the underlying neurological disorder potentiating pseudobulbar affect.

In patients with coronavirus disease 2019 (COVID-19), various cutaneous symptoms have been observed. Herpes zoster (HZ) is an infectious skin disease caused by the varicella-zoster virus (VZV) that, after a primary chickenpox infection, persists dormant in the dorsal root ganglia of cutaneous nerves. Unusual prolonged dermatological symptoms from recovered COVID-19 patients have rarely been recorded. In this report, we describe a case of HZ following recovery from COVID-19.

Peritonitis is a well-known complication seen with peritoneal dialysis. Peritonitis is associated with increased mortality risk and is commonly caused by gram-positive and gram-negative bacteria, but it can also be the result of fungal or viral infections. Therefore, it is imperative to obtain a peritoneal fluid sample to send for cell count with differential, gram stain, and culture prior to starting empiric antibiotic therapy. We report a case of peritoneal dialysis-related peritonitis caused by Enterococcus gallinarum, for which there has only been one other reported case in the medical literature. Our patient was initially placed on vancomycin and cefepime but continued to deteriorate until peritoneal fluid cultures revealed E. gallinarum. Based on sensitivities, the patient was treated with daptomycin and cefazolin, which resolved her peritonitis.

Introduction: Intra-aortic balloon pump (IABP) has been shown to have a neutral effect on patients having cardiogenic shock (CS) in acute coronary syndrome (ACS). However, subgroup analysis of certain studies has shown a beneficial effect of IABP on selected populations presenting with CS. Hypothesis: IABP is associated with improved survival and less in-hospital complications in patients with ACS and CS. Methods: Nationwide Inpatient Sample 2016 and 2017 had been retrospectively analyzed to identify all patients presenting with ACS and CS (n=79260) with appropriate ICD-10-CM codes. Patients with cardiac arrest, tamponade or pulmonary embolism, free wall rupture, ventricular septal defect, severe peripheral artery disease, aortic regurgitation, age greater than 90 or less than 18 have been excluded (n=14055) to include a final population of 65,180. Among them, IABP was used in 22,725 patients. Propensity score matching using the kernel method was used to generate an adjusted odds ratio (OR). Multiple imputations are used to generate missing variables. Results: 34% of patients presenting with CS required IABP in our analysis. Patients requiring IABP are younger and more likely to be male. Patients requiring IABP have higher prevalence of hypertension, obesity, dyslipidemia, and CAD. On propensity-matched analysis, the risk of all-cause in-hospital mortality is similar between two groups regardless of IABP use (p = 0.18). IABP appears to be protective for acute kidney injury (AKI) in non-propensity matched analysis (p = 0.007). There is a higher incidence of mechanical ventilation, bleeding, blood transfusion, coronary artery dissection, hemodialysis requirement, and respiratory failure in the IABP cohort. IABP appears to be protective for complete heart block (CHB) (p = 0.016). Conclusion: IABP use is associated with increased in-hospital complications without any mortality benefit. There appears to be some benefit towards the prevention of AKI and CHB.

Introduction: Heart failure (HF) hospitalizations are associated with increased short-term and long-term risk for venous thromboembolism. We retrospectively analyzed Nationwide Readmission Database (NRD) to identify the incidence of venous thromboembolism (VTE) during index hospitalization based on HF subtypes and whether index VTE events influence 30-day readmission due to VTE. Hypothesis: Venous thromboembolism during index admission can influence 30-day readmission risk between different HF subtypes. Methods: NRD 2012-2014 was used to identify all patients with discharge diagnosis with HF and categorized into HF with reduced ejection fraction (HF-rEF) and (HF-pEF) using appropriate ICD-9-CM codes. After the exclusion of patients with cancer, 950385 patients with HF-rEF, and 798590 patients with HF-pEF were included for final analysis. Multivariate logistic regression and Cox-regression model were used to calculate adjusted Hazard Ration (HR) and Odds Ratio (OR). Results: Patients with HF-rEF were younger, African American, and more likely to be men, whereas HF-pEF population is older, white, and more likely to be women (table 1.). Incidence of anemia, chronic lung disease, hypertension, diabetes, and obesity was higher in the HF-pEF group. In contrast, HF-rEF patients had a higher incidence of prior CABG, PCI, and CAD. HF-pEF patients had lower odds of pulmonary embolism (PE) (OR, 0.80; p < 0.001), deep vein thrombosis (DVT) (OR, 0.73; p < 0.001) and other VTE (OR, 0.50; p < 0.001) during index hospitalization. Patients with HF-pEF who had VTE in index hospitalization had an increased risk of readmission due to DVT (HR, 1.16: 95% CI: 1.07-1.26, p < 0.001). Conclusion: Patients with HF-rEF had a higher incidence of VTE during the index admission, whereas HF-pEF patients with index VTE were more likely to be readmitted within 30-day with DVT.

Objective To retrospectively study the performance of CT-guided biopsy of target prostate lesions at a single institution. Methods Between May 2016 and February 2021, we retrospectively identified all men without rectal access who underwent transgluteal CT-guided biopsy of PIRADS 4 or 5 targets detected on multiparametric MRI (n = 9). Clinical, radiological, and pathological details were collected by review of the electronic medical record, and included age, pre-biopsy prostate specific antigen (PSA) value, prior biopsy history, biopsy targeting technique and procedural details, complications, and final histologic diagnosis. Two targeting techniques were used: Localizing with anatomic landmarks or localizing with contrast enhancement. Results Mean patient age was 69 years (range, 49–74) and mean PSA was 14.6 ng/mL (range 7–23). Four lesions were targeted using anatomic landmarks and 5 were targeted using contrast enhancement. All biopsies were technically successful and all resulted as prostate cancer. Three biopsies showed Gleason 6 cancer and 6 biopsies showed clinically significant prostate cancers with Gleason 7 or above. There were no major complications. 7 patients went on to definitive treatment with surgery or radiation. Conclusion Transgluteal CT-guided biopsy of MRI detected prostate lesions diagnoses clinically significant prostate cancer without complication and therefore should be considered for patients without a rectum.

There has been an increasing prevalence of Moyamoya disorder (MMD) reported from recent US literature. There is a paucity of data available regarding trends of prevalence and epidemiological factors in the United States. To goal of this study was to test the hypotheses that racial-, sex-specific MMD hospitalizations and epidemiological factors have been increasing in the United States over the last decade.In this retrospective observational study, using the National Inpatient Sample (NIS) database from 2005 to 2016, MMD-related hospitalizations in patients aged ≥18 years were identified. Trends of epidemiological factors were analyzed over time using the linear regression model with the significance of differences in trend over time assessed using the Wald test. Sex- and race-specific burden of MMD were calculated using the annual US Census data. Joinpoint regression model was used to evaluate trends of hospitalizations over time.A total of 24,484 adult hospitalizations were identified from January 2005 to September 2015 after excluding18 years. Among them, approximately ~90% were aged ≤60 years, and 73.5% were females. The most common vascular and non-vascular presentations were ischemic stroke (17.3%) and seizures (21%), respectively. The trend of antithrombotic therapy has increased, while extracranial-intracranial bypass has remained stagnant. The actual average hospitalizations of MMD was 10.4 cases/ million population/year (range 4.1-17.9) and varied significantly by sex (females 14.7 [range 6.2-23.6] and males 5.9 [range 1.8-11.9]) over the 2005 to 2016 study period. The burden of hospitalizations also differed by race (African Americans 40.6 [range 32.8-63.7], Asians 24.8 [15.4-34.8], Non-Hispanic Whites 8.1 [range 6.4-11.5], and Hispanics 8.4 [2.8-12.8]) over the 2010 to 2016 study period. Joinpoint regression analysis showed an increasing overall MMD trend across the study period (+11.7%; P 0.001), which was higher in males (+14.5% vs. +10.7%; P 0.001). The Hispanic group had significantly increased hospitalizations over the years (+20.2%; P 0.001).Although overall more prevalent in females, MMD-related hospitalizations are increasing more rapidly in males. Among the racial subpopulations, African Americans had the highest MMD-related hospitalizations, even higher than Asian Americans. MMD-related hospitalizations have increased quicker in Hispanics than in any other racial group.