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Epithelioid hemangioma is a rare neoplasm characterized by locally aggressive behavior and composed of small vessels lined by epithelioid endothelial cells. Its varied presentation poses diagnostic challenges because of its ability to mimic other tumors. An 18-year-old boy presented with a painful dorsal mass on the right wrist, exhibiting features on preoperative imaging consistent with an expansile, radiolucent lesion. Initial bone biopsy suggested potential diagnoses of aneurysmal bone cysts or enchondromas. Surgical intervention, including debridement, adjuvant therapy, and bone graft, was performed. Postoperative immunohistology on intraoperative samples showed the presence of vascular markers, providing a confirmatory diagnosis of epithelioid hemangioma The patient was followed and was able to perform activities without pain for 6 months after surgery. Epithelioid hemangioma of the bone, although uncommon, demands cautious diagnosis, employing advanced techniques like immunohistochemical staining for accurate identification.

We present a case of a 70-year-old male who presented with left-sided weakness and dysarthria. Cranial imaging was suggestive of a cerebellar infarct and the patient was treated with aspirin and clopidogrel. Two months later a fall prompted further cranial imaging, which was concerning for an intracranial mass with vasogenic edema. Computed tomography angiogram (CTA) was negative for vascular lesion. Ultimately, a DSA revealed a Borden III dAVF between the right occipital artery and the posterior cerebellar vein that was treated with endovascular embolization.

Background/Objective: Calcium channel blockers, when taken in overdose quantities, can cause hyperglycemia requiring so-called hyperinsulinemic-euglycemic therapy. The objective of this report was to describe a patient with calcium channel blocker toxicity resulting from overdose of amlodipine. Case Report: A 74-year-old man presented with a fall and loss of consciousness. Prior to this event, he consumed 88 tablets of amlodipine. Medical history was significant for hypertension, hyperlipidemia, and cerebrovascular accident. His vital signs were heart rate of 51 beats/min, blood pressure of 162/137 mm Hg, oxygen saturation of 94% on room air, and respiratory rate of 16 breaths/min. The patient soon became hypotensive. The blood glucose level was 227 mg/dL. Urinalysis was negative for ketones. The patient was diagnosed with calcium channel blocker toxicity and admitted to the intensive care unit. He received continuous insulin infusion and dextrose 25% in water for 5 and 7 days respectively, with a peak insulin infusion rate of 850 U/h. After discontinuation of medications, the glucose level, blood pressure, and heart rate were 82 mg/dL, 127/68 mm Hg, and 86 beats/min, respectively, and he returned to prior functional status. Discussion: Amlodipine is a long-acting dihydropyridine class calcium channel blocking drug. In the overdose setting, amlodipine inhibits calcium uptake by myocytes and release of insulin from pancreatic beta cells. Conclusion: In this case, high-dose insulin euglycemic therapy was effective in the treatment of amlodipine overdose and should be considered in similar cases.

Sturge-Weber syndrome (SWS) is a rare congenital disorder marked by facial port-wine birthmarks, neurological impairments, and ocular anomalies. Our case report describes a 20-year-old man with SWS who presented with right-sided weakness, slurred speech, and oral dyskinesia. Laboratory studies demonstrated elevated prolactin levels, and imaging confirmed a pituitary macroadenoma. While not well-documented, the association between SWS and pituitary macroadenomas is emerging based on current evidence. The potential link may involve embryological, genetic, or hormonal factors influencing the simultaneous development of these conditions. This case highlights the need for a thorough evaluation in patients with SWS, incorporating both neuroimaging and endocrine assessments to manage associated complications effectively. Further research is necessary to investigate the link between SWS and pituitary tumors. Establishing evidence-based guidelines for the screening and management of these patients will improve outcomes and provide a standardized approach to care.

Background: Empirical decisions to select therapies for psoriasis (PSO) and atopic dermatitis (AD) can lead to delays in disease control and increased health care costs. However, routine molecular testing for AD and PSO are lacking. Objective: To examine (1) how clinicians choose systemic therapies for patients with PSO and AD without molecular testing and (2) to determine how often the current approach leads to patients switching medications. Methods: A 20-question survey designed to assess clinician strategies for systemic treatment of AD and PSO was made available to attendees of a national dermatology conference in 2022. Results: Clinicians participating in the survey (265/414, 64% response rate) ranked “reported efficacy” as the most important factor governing treatment choice (P

BACKGROUND:. Continuous renal replacement therapy (CRRT) is the favored renal replacement therapy in critically ill patients. Predicting clinical outcomes for CRRT patients is difficult due to population heterogeneity, varying clinical practices, and limited sample sizes. OBJECTIVE:. We aimed to predict survival to ICUs and hospital discharge in children and young adults receiving CRRT using machine learning (ML) techniques. DERIVATION COHORT:. Patients less than 25 years of age receiving CRRT for acute kidney injury and/or volume overload from 2015 to 2021 (80%). VALIDATION COHORT:. Internal validation occurred in a testing group of patients from the dataset (20%). PREDICTION MODEL:. Retrospective international multicenter study utilizing an 80/20 training and testing cohort split, and logistic regression with L2 regularization (LR), decision tree, random forest (RF), gradient boosting machine, and support vector machine with linear kernel to predict ICU and hospital survival. Model performance was determined by the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) due to the imbalance in the dataset. RESULTS:. Of the 933 patients included in this study, 538 (54%) were male with a median age of 8.97 years and interquartile range (1.81–15.0 yr). The ICU mortality was 35% and hospital mortality was 37%. The RF had the best performance for predicting ICU mortality (AUROC, 0.791 and AUPRC, 0.878) and LR for hospital mortality (AUROC, 0.777 and AUPRC, 0.859). The top two predictors of ICU survival were Pediatric Logistic Organ Dysfunction-2 score at CRRT initiation and admission diagnosis of respiratory failure. CONCLUSIONS:. These are the first ML models to predict survival at ICU and hospital discharge in children and young adults receiving CRRT. RF outperformed other models for predicting ICU mortality. Future studies should expand the input variables, conduct a more sophisticated feature selection, and use deep learning algorithms to generate more precise models.

Category: Other; Ankle Introduction/Purpose: The Accreditation Council for Graduate Medical Education (ACGME) Surgical Review Committee monitors the quantity of experiences through Current Procedural Terminology (CPT) codes logged by residents based on the procedures they perform. The ACGME currently requires a minimum of 20 specific foot and ankle procedures to be completed prior to graduation. These are defined as 15 'ankle fracture' cases and 5 'ankle, hindfoot, or midfoot arthroscopy' cases. The year 2020 marked a milestone change in residency training, as the Allopathic (MD) and Osteopathic (DO) residency accreditation merger resulted in unified graduate medical education training. The purpose of this study was to better understand the effect the merger had on the average number of cases, as well as the defined minimum cases for graduating orthopedic residents. Methods: A retrospective analysis of ACGME case logs examined the max and average number of adult orthopaedic cases related to both Leg/Ankle and Foot/Toes performed by graduating orthopaedic surgery residents from 2014 to 2023, spanning a 10-year period. Trends in case exposure were analyzed by assessing the average number of adult orthopaedic procedures during the study period. All data were sourced directly from the ACGME website.1 Descriptive statistics will be used along with unpaired t-tests to examine if there are statistical differences between pre and post merger averages (Microsoft Corporation, 2018. Microsoft Excel). Results: In 2014, 151 programs graduated 684 residents, compared to 197 programs in 2023 graduating 884 residents. The overall average of leg/ankle procedures prior to the merger was 176.74 (range 151.9-200.8, SD 18.9), which increased to 212.93 post-merger (range 206.5-219.9, SD 6.7; p = 0.006). Similarly, the total number of foot/toes procedures increased from a mean of 72.6 (range 62.5-83, SD 7.3) pre-merger to 82.9 post-merger (range 83.2-83.9, SD 1.1; p = 0.023). The average number of ankle fractures pre-merger was 58.3 (range 53-62.3, SD 3.7), which increased to 68.2 post-merger (range 66.6-69.7, SD 1.5; p < 0.01). Additionally, the average number of ankle arthroscopy procedures increased from 13.8 pre-merger (range 11.4-15.6, SD 1.7) to 15.3 post-merger (range 14.8-15.9, SD 0.5; p = 0.9). Conclusion: The merger between MD and DO residency programs in 2020 has led to a significant increase in the average number of orthopedic surgery procedures related to the foot and ankle performed by graduating residents. This indicates a positive impact on the training and exposure of orthopedic surgery residents in these areas. The findings suggest that the merger has helped to enhance the educational experience and preparedness of orthopedic surgery residents in foot and ankle procedures, meeting the ACGME requirements for graduation.

OBJECTIVES:. Continuous renal replacement therapy (CRRT) and shock are both associated with high morbidity and mortality in the ICU. Adult data suggest renoprotective effects of vasopressin vs. catecholamines (norepinephrine and epinephrine). We aimed to determine whether vasopressin use during CRRT was associated with improved kidney outcomes in children and young adults. DESIGN:. Secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), a multicenter, retrospective cohort study. SETTING:. Neonatal, cardiac, PICUs at 34 centers internationally from January 1, 2015, to December 31, 2021. PATIENTS/SUBJECTS:. Patients younger than 25 years receiving CRRT for acute kidney injury and/or fluid overload and requiring vasopressors. Patients receiving vasopressin were compared with patients receiving only norepinephrine/epinephrine. The impact of timing of vasopressin relative to CRRT start was assessed by categorizing patients as: early (on or before day 0), intermediate (days 1–2), and late (days 3–7). INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Of 1016 patients, 665 (65%) required vasopressors in the first week of CRRT. Of 665, 248 (37%) received vasopressin, 473 (71%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (death, renal replacement therapy dependence, and/or > 125% increase in serum creatinine from baseline 90 days from CRRT initiation), and 195 (29%) liberated from CRRT on the first attempt within 28 days. Receipt of vasopressin was associated with higher odds of MAKE-90 (adjusted odds ratio [aOR], 1.80; 95% CI, 1.20–2.71; p = 0.005) but not liberation success. In the vasopressin group, intermediate/late initiation was associated with higher odds of MAKE-90 (aOR, 2.67; 95% CI, 1.17–6.11; p = 0.02) compared with early initiation. CONCLUSIONS:. Nearly two-thirds of children and young adults receiving CRRT required vasopressors, including over one-third who received vasopressin. Receipt of vasopressin was associated with more MAKE-90, although earlier initiation in those who received it appears beneficial. Prospective studies are needed to understand the appropriate timing, dose, and subpopulation for use of vasopressin.

Background: There is a paucity of validated risk stratification tools to assess which patients can safely and predictably undergo outpatient total hip (THA) or knee arthroplasty (TKA) in an ambulatory surgery center (ASC). Methods: Our novel patient selection tool was prospectively applied to 190 consecutive primary THA and TKA performed by a single surgeon at a single ASC. We identified the proportion of patients discharged home the same day, those requiring a one-night stay, or those with failed discharge within 23 hours. A retrospective chart review was performed to determine if any demographic parameters were risk factors for an overnight stay. Results: Overall, 190 (100%) patients selected for outpatient THA and TKA were discharged home within 23 hours. One hundred and four patients (55%) were discharged the same day of surgery, whereas 86 (45%) required overnight stay and were discharged on postoperative day 1. Female sex (odds ratio [OR]: 4.1, 95% confidence interval [CI]: 2.0-8.2, P < .001), THA (OR: 2.5, 95% CI: 1.1-5.5, P = .022), and heavier body mass index (OR: 1.0, 95% CI: 1.0-1.2, P = .022) were identified as independent risk factors for staying overnight in the ASC. Conclusions: In this pilot study, we found that 100% of outpatient THA and TKA-eligible patients were able to be discharged home by postoperative day 1. Additionally, we found that this selection tool is safe and effective at predicting short-stay discharge in an ASC.

CONTEXT:. Conventional MRI is incompatible with extracorporeal membrane oxygenation (ECMO) cannulas and pumps. Ultra-low-field portable MRI (ULF-pMRI) with 0.064 Tesla may provide a solution, but its safety and compatibility is unknown. HYPOTHESIS:. ULF-pMRI does not cause significant displacement and heating of ECMO cannulas and does not affect ECMO pump function. METHODS AND MODELS:. ECMO cannulas in various sizes were tested ex vivo using phantom models to assess displacement force and heating according to the American Society for Testing and Materials criteria. ECMO pump function was assessed by pump flow and power consumption. In vivo studies involved five female domestic pigs (20–42 kg) undergoing different ECMO configurations (peripheral and central cannulation) and types of cannulas with an imaging protocol consisting of T2-weighted, T1-weighted, FLuid-Attenuated Inversion Recovery, and diffusion-weighted imaging sequences. RESULTS:. Phantom models demonstrated that ECMO cannulas, both single lumen with various sizes (15–24-Fr) and double lumen cannula, had average displacement force less than gravitational force within 5 gauss safety line of ULF-pMRI and temperature changes less than 1°C over 15 minutes of scanning and ECMO pump maintained stable flow and power consumption immediately outside of the 5 gauss line. All pig models showed no visible motion due to displacement force or heating of the cannulas. ECMO flow and the animals’ hemodynamic status maintained stability, with no changes greater than 10%, respectively. INTERPRETATION AND CONCLUSIONS:. ULF-pMRI is safe and feasible for use with standard ECMO configurations, supporting its clinical application as a neuroimaging modality in ECMO patients.

ABSTRACT: Background: Surgical site infection (SSI) is a common yet serious complication of cervical spine surgery. While initially thought to be clinically insignificant, Cutibacterium acnes (C. acnes) is an important cause of infection. The purpose of this study was to investigate the ability of a hydrogen peroxide (H2O2) application during standard presurgical skin preparation to reduce the burden of C. acnes in patients undergoing cervical spine surgery. Methods: This was a retrospective review of prospectively collected data. Subjects were randomly assigned to either standard surgical preparation plus H2O2 (experimental) or without H2O2 (control). Prescrub, postscrub, and dermal cultures were obtained to assess the C. acnes burden after cultures on an aerobic and anaerobic growth medium were held for 21 days. Multivariate analysis was conducted to determine factors associated with presence of C. acnes. Outcome measures included the results of intraoperative cultures and the development of a SSI within 90 days postoperatively. Results: Patients (n=86) undergoing elective 2- or 3-level fusion via anterior approach were included. Prior to application of the antiseptic solution, 65% (28/43) of the experimental cohort and 77% (33/43) of the control cohort had positive C. acnes cultures (p=.34). Following application of antiseptic solution, there were no differences in positive C. acnes culture rates between the experimental and control cohorts in the epidermal (30% vs. 28%, p=1.00) or dermal (40% vs. 42%, p=1.00) cultures. No differences in the rates of C. acnes eradication from preantiseptic to postantiseptic application occurred for epidermal (p=1.00) or dermal (p=1.00) skin layers. None of the factors were associated with positive C. acnes epidermal cultures on multivariable logistic regression analysis (p>.05). Conclusions: While there is potential for H2O2 to reduce the positive culture rate of C. acnes in cervical spine patients, no difference was seen when compared to standard surgical skin preparation.

Therapeutic Area: Alternative and Complimentary Approaches Background: The human microbiome, encompassing diverse microbial communities inhabiting various body sites, plays a pivotal role in maintaining physiological homeostasis and modulating disease susceptibility. Among these microbial ecosystems, the skin and gut microbiota have garnered significant attention due to their potential implications in numerous health conditions, including cardiovascular diseases (CVDs). The emerging concept of the gut-skin-heart axis underscores the intricate interplay between gut microbiota, skin microbiota, and cardiovascular health. While extensive research has focused on the role of gut microbiota in cardiovascular health, the contribution of skin microbiota to cardiovascular pathophysiology remains largely unexplored. This paper aims to provide a comprehensive review of the current literature on the role of skin microbiota in cardiovascular health, examining potential mechanisms underlying the gut-skin-heart axis and identifying areas for future research to advance our understanding of this groundbreaking topic. Methods: To conduct this literature review, a systematic search of databases including PubMed and Google Scholar was performed using relevant keywords such as ''skin microbiota,'' ''cardiovascular health,'' ''gut-skin-heart axis,'' and related terms. Studies published in peer-reviewed journals up to the present date were included, with a focus on original research articles, reviews, and meta-analyses investigating the relationship between skin microbiota and cardiovascular health. Additionally, relevant references cited within identified articles were cross-referenced to ensure comprehensive coverage of the topic. Studies examining the composition, dynamics, and potential mechanisms of skin microbiota involvement in cardiovascular pathophysiology were analyzed to provide insights into the current understanding of this field. Results: Emerging evidence suggests a significant association between skin microbiota dysbiosis and cardiovascular diseases. Studies have demonstrated alterations in skin microbiota composition in various dermatological conditions, including psoriasis, atopic dermatitis, and acne, which are also recognized risk factors for CVDs. For instance, research by Smith et al. and Johnson et al. found dysregulated skin microbiota composition correlated with increased cardiovascular risk in patients with psoriasis and coronary artery disease, respectively. Moreover, investigations such as those by Mei et al. have highlighted sex-specific differences in skin microbiota species and their potential influence on blood pressure regulation, further emphasizing the need for additional research on the skin microbiome's role in cardiovascular health. Additionally, the presence of skin microbiota organisms, such as coagulase-negative Staphylococci, including Staphylococcus haemolyticus and Staphylococcus lugdunensis, has been implicated in systemic infections, including infective endocarditis, further underlining the relevance of skin microbiota in cardiovascular pathophysiology. These findings underscore the importance of further research to analyze the mechanisms underlying the gut-skin-heart axis and its implications for cardiovascular health management. Conclusions: In conclusion, the gut-skin-heart axis represents an emerging novel topic in cardiovascular research, emphasizing the intricate interplay between gut microbiota, skin microbiota, and cardiovascular health. While the role of gut microbiota in cardiovascular diseases has been extensively studied, the contribution of skin microbiota still needs to be explored. However, it holds significant promise for advancing our understanding of cardiovascular pathophysiology. By further understanding the mechanisms underlying the gut-skin-heart axis and identifying potential therapeutic targets, future research endeavors may lead to innovative preventive and therapeutic strategies for cardiovascular diseases. Ultimately, unraveling the complexities of the gut-skin-heart axis may pave the way for personalized approaches to cardiovascular diagnosis, treatment, and management.

Therapeutic Area: Other Background: The intricate interplay between the skin immune system and cardiovascular health has emerged as a compelling area of investigation with profound implications for preventive and therapeutic strategies in cardiovascular diseases (CVDs). While traditional risk factors such as hypertension and dyslipidemia have long been recognized as contributors to CVD development, recent literature underscores the pivotal role of immune-mediated mechanisms, particularly those involving the skin, in cardiovascular pathophysiology. This review aims to analyze the current understanding of how cutaneous immune modulation influences cardiovascular health, exploring potential therapeutic interventions and highlighting avenues for future research. By furthering our understanding of the complex relationship between the skin immune system and CVDs, this review seeks to bridge the gap between dermatology and cardiology, offering insights that could revolutionize approaches to CVD prevention and therapy. Methods: This literature review systematically examined existing research on the interplay between the skin immune system and cardiovascular health to study potential preventive and therapeutic strategies for cardiovascular diseases (CVDs). Relevant articles were identified through comprehensive searches of electronic databases including PubMed and Google Scholar, using keywords such as ''skin immune system,'' ''cardiovascular health,'' ''atherosclerosis,'' ''psoriasis,'' ''atopic dermatitis,'' and ''immunomodulatory therapy.'' Articles published in peer-reviewed journals up to the present date were included, with a focus on original research articles, review papers, and meta-analyses. Additionally, reference lists of retrieved articles were manually searched to identify additional relevant studies. Data extraction involved summarizing key findings related to the role of cutaneous immune modulation in cardiovascular pathophysiology, potential mechanisms linking skin immunity to CVD risk, therapeutic interventions targeting the skin immune system, and areas for future research. The synthesis of findings was organized thematically to provide a comprehensive overview of the current understanding of the topic. Results: The review revealed a substantial body of literature highlighting the intricate relationship between the skin immune system and cardiovascular health. Studies consistently demonstrated the involvement of immune-mediated mechanisms in the pathogenesis of cardiovascular diseases, with particular emphasis on inflammation and immune cell activation. Notably, inflammatory pathways within the vessel wall, driven by cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha), were implicated in endothelial dysfunction and atherosclerosis development. Moreover, the skin immune system was found to play a significant role in modulating systemic inflammation and cardiovascular risk, with conditions like psoriasis and atopic dermatitis associated with increased CVD prevalence. Mechanistic insights suggested that cutaneous immune responses could influence cardiovascular health through the release of pro-inflammatory mediators, dysregulation of the skin microbiota, and interactions between skin-resident immune cells and circulating immune cells. Therapeutically, interventions targeting skin inflammation and immune dysregulation, including biologic agents and microbiome-targeted approaches, showed promise in mitigating cardiovascular risk. However, further research is needed to explore and understand specific molecular pathways, validate therapeutic efficacy in clinical settings, and identify novel therapeutic targets for cardiovascular disease prevention and therapy. Conclusions: In conclusion, the emerging evidence linking cutaneous immune modulation to cardiovascular health underscores the importance of considering skin immunity as a potential target for preventive and therapeutic interventions in CVD. While preliminary studies have shown promising results, further research is needed to interpret the underlying mechanisms and validate the efficacy of immunomodulatory therapies targeting the skin in clinical settings. By bridging the gap between dermatology and cardiology and leveraging insights from skin immunology, we can develop innovative approaches for reducing cardiovascular risk and improving patient outcomes. Ultimately, integrating cutaneous immune modulation into cardiovascular disease management strategies has the potential to revolutionize preventive cardiology and enhance the quality of care for individuals at risk of CVD.

Therapeutic Area: CVD Prevention – Primary and Secondary Background: Cholesterol-lowering medications such as HMG-CoA reductase inhibitors or statins are a guideline recommendation for the prevention of cardiovascular events in patients with diabetes over the age of 40. High-intensity statins can reduce low-density lipoprotein LDL cholesterol levels by as much as 50%. The optimal LDL level for statin medication patients has not been well studied. Our study aimed to determine the optimal LDL range for cardiovascular outcomes for primary and secondary prevention among patients with diabetes taking a statin. Methods: A retrospective observational study of patients diagnosed with type 2 diabetes mellitus receiving statin therapy was evaluated and separated into groups based on their low-density lipoprotein (LDL) values, 100 mg/dL. The primary outcome of acute coronary syndrome and ischemic cerebrovascular accidents were analyzed in primary prevention and secondary prevention groups. A chi-squared analysis was used to determine which LDL range was deemed more effective and whether the LDL range was dependent on prevention outcomes. Additionally, a multinomial logistic regression was used to determine predictors for successful prevention management. Results: Of the 11,529 patients, most of the patients were male (52.2%) and had an LDL range of >100 mg/dL (50.98%), followed by 71-100 mg/dL (26.90%), 51-70 mg/dL (12.23%), and < 50mg/dL (9.87%). Primary prevention and LDL range were statistically dependent (χ2=12.92, p=0.044), with the LDL range of 56-70 mg/dL displaying a lower-than-expected frequency for outcomes in primary prevention (z=-2.91). On multinomial logistic regression for cardiovascular outcomes LDL group was not a significant predicator (OR , 95% CI 0.86-1.60, p

Pigmented villonodular synovitis is an uncommon benign neoplastic proliferation associated with the synovium, bursa, or tendon sheaths; most commonly occurring in the third to fourth decade of life. It is rare in children and may be painful or painless. Magnetic resonance imaging is the diagnostic study of choice. In this report, the radiologic, ultrasound, and magnetic resonance imaging findings of pigmented villonodular synovitis of the flexor hallucis longus in a 12-year-old girl are discussed. We briefly review the surgical findings as well. To our knowledge, this is the first case report that simultaneously synthesizes the imaging findings of 3 diagnostic imaging modalities for optimal visualization and is the youngest reported case of pigmented villonodular synovitis of the flexor hallucis longus tendon.