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Study design and objection: Intradural disc herniation is a unusual disease associated with spinal surgery. The definitive diagnosis of intradural herniation depends on intraoperative findings. Summary of background data: We present the case of a 63-year-old woman with backache and left sciatica radiation for more than two months. The L2/3 laminectomy and discectomy were performed after magnetic resonance imaging (MRI) study; however, no disc rupture was noted during surgery. Follow-up lumbar spine MRI revealed one large, ruptured disc. The patient underwent revision surgery with durotomy. The large intradural disc was found and removed piece by piece. Methods, Results, and Conclusions: Intradural disc herniation, especially large herniation, is hard to diagnose specifically despite the progression of neuroradiologic imaging techniques. A durotomy procedure should be considered if there is a missing ruptured disc or a palpable intradural mass during surgery.

Background: New-onset postoperative atrial fibrillation is associated with adverse clinical outcomes in older adults. Poor preoperative sleep quality is a putative modifiable risk factor. The relationships between new-onset postoperative atrial fibrillation and preoperative sleep structure in older adults undergoing elective cardiac surgery were investigated at a single center. Methods: This was a prespecified substudy within a prospective observational study of perioperative electroencephalographic markers (ClinicalTrials.gov; NCT03291626). We analyzed preoperative sleep recordings from 71 cardiac surgical patients aged ≥60 years without a prior history of atrial fibrillation. Overnight recordings were acquired using a consumer-grade headband and underwent manual sleep staging. Electroencephalographic slow wave activity (power in the 0.5-4 Hz frequency band) was computed in 1-minute intervals for non-rapid eye movement sleep stages. Associations between new-onset postoperative atrial fibrillation incidence and sleep measures were evaluated using univariate logistic regression models and multivariate logistic regression models including age and sex. Results: New-onset postoperative atrial fibrillation was present in 22 of 71 (31%) patients. A higher preoperative percentage of total sleep time in non-rapid eye movement stage 1 was associated with new-onset postoperative atrial fibrillation (median difference of 5.4%, P = .0002, Mann-Whitney U-test), independent of age and sex. No associations were observed between new-onset postoperative atrial fibrillation and other sleep metrics, including slow wave activity (all P > .05, Mann-Whitney U-test). Conclusions: Excess preoperative non-rapid eye movement stage 1 sleep, consistent with greater sleep fragmentation, is a potential modifiable target for mitigating new-onset postoperative atrial fibrillation risk in older adults undergoing elective cardiac surgery requiring cardiopulmonary bypass.

Background: Globally significant variation in treatment and course of heart valve disease (HVD) exists, and outcome measurement is procedure focused instead of patient focused. This article describes the development of a patient-related (International Consortium for Health Outcomes Measurement) standard set of outcomes and case mix to be measured in patients with HVD. Methods: A multisociety working group was formed that included patient representatives and representatives from scientific cardiology and cardiothoracic surgery societies that publish current guidelines for HVD. The standard set was developed to monitor the patient’s journey from diagnosis to treatment with either a surgical or transcatheter procedure. Candidate clinical and patient-reported outcome measures (PROMs) and case mix were identified through benchmark analyses and systematic reviews. Using an online modified Delphi process, the working group voted on final outcomes/case mix and corresponding definition. Results: Patients with aortic/mitral/tricuspid valve disease or root/ascending aorta >40 mm were included in the standard set. Patients entered the dataset when the diagnosis of HVD was established, allowing outcome measurement in the preprocedural, periprocedural, and postprocedural phases of patients’ lives. The working group defined 5 outcome domains: vital status, patient-reported outcomes, progression of disease, cardiac function and durability, and complications of treatment. Subsequently, 16 outcome measures, including 2 patient-reported outcomes, were selected to be tracked in patients with HVD. Case-mix variables included demographic factors, demographic variables, echocardiographic variables, heart catheterization variables, and specific details on aortic/mitral/tricuspid valves and their specific interventions. Conclusions: Through a unique collaborative effort between patients and cardiology and cardiothoracic surgery societies, a standard set of measures for HVD was developed. This dataset focuses on outcome measurement regardless of treatment, moving from procedure- to patient-centered outcomes. Implementation of this dataset will facilitate global standardization of outcome measurement, allow meaningful comparison between health care systems and evaluation of clinical practice guidelines, and eventually improve patient care for those experiencing HVD worldwide.

Background: It is still controversial whether prosthesis-patient mismatch (PPM) adversely affects long-term outcomes after aortic valve replacement (AVR). The aim of this study was to examine whether flow-adjusted pressure gradient is a valid new indicator of long-term outcomes. Methods: Data collected from 184 patients undergoing isolated AVR for severe aortic stenosis from October 2012 to September 2016 were analyzed. Flow-adjusted pressure gradient was defined as mean pressure gradient divided by stroke volume (MPG/SV). The effect of PPM and MPG/SV on long-term cardiac events and survival was evaluated. Results: Overall mortality was 8.2%, and the incidence of cardiac events was 9.2% (median follow-up period, 5.5 years). Moderate to severe PPM was present in 30.0% of patients and did not correlate with cardiac events (P = .13). The mean pressure gradient and stroke volume were also not predictive, but MPG/SV was significantly associated with cardiac events (P = 0.016), and the cutoff value of MPG/SV was 0.24 mm Hg/mL. MPG/SV ≥ 0.24 mm Hg/mL was detected as an independent risk factor (adjusted hazard ratio, 5.67; P < .001). The 5-year cardiac event-free rate was lower in patients with MPG/SV ≥ 0.24 mm Hg/mL (72.7% ± 9.6% vs 96.6% ± 1.7%; P < .001). Additionally, the left ventricular mass index at 1 month was significantly lower in patients with MPG/SV ≥ 0.24 mm Hg/mL (P = .028), although there was no significant difference at 6 months (P = .12). Conclusions: Flow-adjusted pressure gradient has the potential to be a better predictor of long-term outcomes after AVR.

Background: Alpha-gal syndrome from tick bites, due to sensitivity to alpha-gal, can cause severe allergies. Heart valve implants contain alpha-gal, yet alpha-gal syndrome screening is not standard before valve replacement. This study examines perioperative outcomes in patients with alpha-gal antibodies. Methods: This is a single-institution prospective cohort study of patients undergoing bioprosthetic aortic valve replacement between January 2022 and January 2023. Anti-alpha-gal immunoglobulin E levels were measured, with primary outcomes being severe allergic reactions and in-hospital mortality, and secondary outcomes including intensive care unit and hospital stay. Results: Of 155 patients, 32.7% (n = 19) of surgical aortic valve replacement and 29.9% (n = 29) of transcatheter aortic valve replacement patients had detectable immunoglobulin E levels without subsequent serious allergic reactions or in-hospital mortality. Postoperative hospital stay and valve function were similar across groups. Conclusions: In this study, sensitization to alpha-gal was not associated with serious allergic reactions and did not affect immediate aortic valve function after surgical aortic valve replacement or transcatheter aortic valve replacement.

When tumor is located in the superior segment of the lower lobe (S6) close to the intersegmental plane with the posterior basal segment (S10), bisegmentectomy of S6 and S10 is oncologically feasible and reasonable to preserve lung parenchyma. However, this bisegmentectomy is technically challenging because of the complex anatomy of S10. Herein, we report a successful case of left S6+S10 segmentectomy by a robotic approach with sufficient surgical margin. A robotic approach is suitable for such a complex segmentectomy of the lower lobe because of the good looking-up high-definition 3-dimensional view.

Background: Although the likelihood of needing a permanent pacemaker (PPM) after tricuspid valve (TV) repair has been thought to be low compared with TV replacement, the incidence and determinants are controversial. This study aimed to evaluate the incidence and risk factors for PPM implantation after TV repair. Methods: A total of 1237 consecutive patients undergoing TV repair from 1997 to 2019 were reviewed using a prospectively maintained database, and 1058 patients were enrolled. Results: Incidence of PPM implantation was 10.3% (n = 109). Median time to PPM implantation was 7 (range, 6-9) days. Indications for PPM implantation were heart block (n = 62, 56.9%), junctional or sinus bradycardia (n = 21, 19.3%), and ventricular arrhythmia (n = 17, 15.6%). Likelihood of PPM varied with concurrent procedures: left ventricular assist device (3.4%), mitral repair (11.2%), mitral valve replacement (13.7%), aortic and mitral valve replacement (19.2%), and isolated tricuspid repair (6.5%). Older age (odds ratio [OR], 1.020; 95% CI, 1.003-1.036), prior mediastinal radiation (OR, 4.106; 95% CI, 1.598-10.554), and concomitant mitral and aortic valve replacement (OR, 1.963; 95% CI, 1.046-3.683) were risk factors, and concomitant left ventricular assist device implantation (OR, 0.325; 95% CI, 0.139-0.759) was a protective factor for PPM implantation. PPM implantation did not affect the early outcomes, overall survival (P =.287), or cumulative incidence of recurrent moderate or greater tricuspid regurgitation (P =.890) or TV reoperation (P =.602). Conclusions: The likelihood of PPM implantation after TV repair is relatively high, but PPM implantation does not affect the early and long-term clinical outcomes. Older age, prior mediastinal radiation, and concomitant mitral and aortic valve replacement are risk factors, and concomitant left ventricular assist device implantation is a protective factor for PPM implantation after TV repair.

Background: This study assessed the possibility of a bridge to recovery using the Berlin Heart EXCOR and the histologic characteristics of pediatric patients with dilated cardiomyopathy accompanied by a left ventricular noncompaction phenotype. Methods: Of the 17 pediatric patients with dilated cardiomyopathy who underwent Berlin Heart EXCOR implantation between 2013 and 2020, 6 were diagnosed with left ventricular noncompaction association. The patients were classified into 2 groups: the dilated cardiomyopathy group and dilated cardiomyopathy with the left ventricular noncompaction phenotype group. The histologic characteristics of the left ventricular myocardium and left ventricular function after Berlin Heart EXCOR implantation were compared. Results: Cardiac recovery was not observed in the dilated cardiomyopathy with left ventricular noncompaction group. In contrast, 6 patients (55%) in the dilated cardiomyopathy group achieved cardiac recovery, and the Berlin Heart EXCOR was explanted. The degree of myocardial fibrosis was significantly higher in the dilated cardiomyopathy with the left ventricular noncompaction phenotype group than in the dilated cardiomyopathy group (P < .05). The final follow-up left ventricular ejection fraction and end-diastolic diameter during Berlin Heart EXCOR support improved significantly compared with the preimplantation variables in the dilated cardiomyopathy group (both P < .001); the dilated cardiomyopathy with left ventricular noncompaction phenotype group showed no improvements (P = .84 and P = .37, respectively). Conclusions: The left ventricular noncompaction phenotype associated with dilated cardiomyopathy may adversely affect the rate of cardiac recovery with Berlin Heart EXCOR.

Background: We hypothesize that previous COVID-19 infection could be associated with postoperative complications (POCs) and outcomes of thoracic surgery for lung cancer. It is unknown whether the respiratory damage caused by COVID-19 infection is permanent. In addition, there is a lack of studies investigating POCs and prior COVID-19 infection in thoracic surgery. Methods: A retrospective study was performed on patients who underwent resections for lung cancer between May 2020 and July 2022. Variables relevant to the Society of Thoracic Surgeons database were collected, as well as COVID-19 status. The primary outcome was postoperative complications. Results: A total of 361 patients underwent a resection for lung cancer. Patients with a prior COVID-19 infection (n = 21) had significantly more POCs than patients without a history of COVID-19 infection (n = 340, P < .05). Pneumothorax and infections requiring intravenous antibiotics were significantly enriched in patients with a prior COVID-19 infection. COVID-19 infection was independently associated with increased POCs at multivariable analysis (adjust odds ratio, 4.36; 95% CI, 1.48-12.8). Matched case-control analysis also reviewed similar findings, where COVID-19 infection was the only significant variable as a risk factor for POCs (P < .05). Conclusions: After a COVID-19 infection, patients undergoing lung cancer resections were at an increased risk of POCs. This suggests that a previous COVID-19 infection should be considered as a potential risk factor for complications after lung cancer resections.

Background: The Ross procedure can be an ideal option in infective endocarditis (IE) due to greater resistance to infection. However, limited literature has highlighted the comparison with conventional prostheses in this setting. Methods: Between February 2013 and September 2022, 25 patients (median age, 50 years) underwent a Ross procedure for IE (Ross group). The results were compared with those after other aortic valve procedures (aortic valve replacement and aortic root replacement) for IE (n = 37, other group. Results: The patients in the Ross group included more intravenous drug users and had more prosthetic valve endocarditis and annular abscess formation compared with the other group. Although cardiopulmonary bypass time and aortic cross-clamp time were significantly longer (P < .001 and P = .003, respectively) and the blood requirements were significantly higher (P = .001) in the Ross group, most postoperative short-term outcomes were equivalent between the 2 groups. During follow-up, 1 patient (4%) required reoperation in the Ross group, whereas 6 patients (16%) required reoperation in the other group. Freedom from composite events was significantly better in the Ross group (P = .04). Multivariable analysis found the Ross procedure, compared with other procedures, was a significant independent protective factor for composite end points (P = .03). Conclusions: For IE, despite surgical complexity, the Ross procedure yielded short-term outcomes similar to other procedures. In the midterm, the Ross procedure provides a lower reoperation rate, resulting in significantly fewer composite events. The Ross procedure appears to be a better option for patients with IE, but long-term follow-up is necessary.

Thoracic SMARCA4-deficient undifferentiated tumors (SMARCA4-UT) may be effectively managed with immune checkpoint inhibitors; however, the management of posttreatment exacerbations remains uncertain. A 48-year-old man underwent chemotherapy (cisplatin and pemetrexed) along with PD-L1 and CTLA-4 inhibitors, resulting in significant improvement. Subsequently, maintenance therapy was initiated but discontinued because of drug-induced pneumonia. Although prednisone treatment resolved the pneumonia, salvage surgery was performed for exacerbation of an enlarged chest tumor and lymph nodes. No additional postoperative treatment was administered, and the patient has completed 2.5 years of treatment. This case highlights the potential efficacy of salvage surgery in the management of SMARCA4-UT exacerbations.

Background: Thoracic endovascular aortic repair is a key treatment of acute type B aortic dissection. We recognized the importance of managing type B aortic dissections from their onset and established our strategy in 2013. Here, we report the early and late outcomes of our comprehensive strategy for the management of type B aortic dissections. Methods: This was a single-institution, observational, retrospective study. Between April 2013 and March 2024, 227 consecutive patients with acute type B aortic dissection were admitted to our institute and treated by our strategy. Early and late outcomes were also assessed for all patients. Results: Thoracic endovascular aortic repair plus optimal medical treatment was performed to close the primary entry tear in 90 patients (40%) in the acute (12%), subacute (14%), and chronic (14%) phases. Optimal medical treatment alone was performed in 137 patients (60%). The early and late outcomes showed significant improvement. Conclusions: Our strategy provided excellent early and late outcomes of acute type B aortic dissection, avoided postoperative paraplegia, and completely prevented thoracoabdominal aortic replacement.

Background: Preoperative opioid use (OU) is a strong risk factor for poor postoperative outcomes in other surgical populations but has not been explored in lung transplant (LT) recipients nationally. Methods: The study identified adult (aged ≥18 years) US lung transplant (LT) recipients from 2011 to 2021 in the Scientific Registry of Transplant Recipients with prescription data through a pharmacy data set. Posttransplantation ventilatory support, infection, and mortality by pretransplantation OU (prescription fill ≤6 months before transplantation) were compared using multivariable regression. Results: Among 17,285 LT recipients, 17.9% had pretransplantation OU. The odds of posttransplantation opioid prescription fill were 3.18-fold higher 0 to 6 months after transplantation (adjusted odds ratio [aOR], 3.18; 95% CI, 2.91-3.47; P < .001) and 14.29-fold higher 6 to 12 months after transplantation (aOR, 14.29; 95% CI, 12.61-16.19; P < .001) among LT recipients with vs without pretransplantation OU. Pretransplantation OU was associated with 16% higher posttransplantation mortality (adjusted hazard ratio, 1.16; 95% CI, 1.09-1.25; P < .001) and a higher risk of ventilator use >48 hours (aOR, 1.14; 95% CI, 1.04-1.25; P = .006). Conclusions: Pretransplantation OU was the strongest independent risk factor for posttransplantation OU and was associated with greater morbidity and mortality. Reducing pretransplantation and posttransplantation OU could benefit LT recipients and should be explored.

Achromobacter xylosoxidans, a rare gram-negative rod, often causes pneumonia. Here, we describe the case of a previously healthy 78-year-old woman who worked at a vegetable plant nursery. A 4.5-cm cavitary lesion with a 2.5-cm-diameter lobulated nodule in the left lingula segment, resembling an aspergillosis fungus ball, was coincidentally detected on chest computed tomography. Bronchoscopic culture eventually revealed A. xylosoxidans, which was sensitive to penicillin; however, the infection did not respond to oral antibiotics. Thus, surgical resection is likely to be indicated for A. xylosoxidans infection that mimics aspergillosis.

A 70-year-old man was referred to our hospital for mediastinal malignant neoplasm. Chest computed tomography revealed a 20-cm mass in the middle mediastinum with displacement of the superior vena cava, left innominate vein, and right upper lobe. Tumor resection, right upper lobectomy, combined resection of the left brachiocephalic vein and superior vena cava, and revascularization were performed. It was pathologically diagnosed as an undifferentiated pleomorphic sarcoma, and the patient experienced no recurrence for 4 years. Although the prognosis of mediastinal pleomorphic sarcoma cases is poor, complete surgical resection may lead to long-term survival.

Background: Temporary mechanical circulatory support (tMCS) may be necessary to treat low cardiac output syndrome after mitral valve surgery (MVS) for chronic severe mitral regurgitation (MR). However, prevalence and predictors remain undetermined. Methods: This single-center retrospective cohort study included 443 patients who underwent primary MVS for degenerative, ischemic, or functional MR between January 2013 and June 2023. Patients requiring tMCS intraoperatively or postoperatively were compared with patients who did not require tMCS. Multivariable logistic regression identified independent risk factors for tMCS requirement. Results: tMCS was required in 12 of 443 patients (2.7%), with degenerative (2.1%), functional (1.8%), and ischemic (8.3%) MR. Independent risk factors for tMCS requirement were preoperative left ventricular ejection fraction

Thoracoscopic right medial-basal (S7) segmentectomy is technically challenging due to its small size, depth, and anatomical complexity, especially through a uniportal thoracoscopic approach because of the limited angulation of the surgical instruments or staplers used. Herein, we report a successful case of right S7 segmentectomy through a uniportal approach with sufficient surgical margin. Key aspects are to mobilize the lung by dissecting the pulmonary ligament, dividing a fissure, and exposing the pulmonary vein branches to the periphery, which allowed us to perform smooth and safe stapling through the single skin incision.

The BCG vaccine is effective in preventing severe tuberculosis infections in infants and young children, and it is commonly administered in Japan to those aged between 5 to 8 months. Although the incidence of adverse reactions is low, disseminated lymphadenitis and osteomyelitis have been reported as potential side effects. We encountered a case of BCG osteomyelitis with typical imaging findings. Provided the clinical presentation and imaging features are recognized, it is possible to diagnose BCG osteomyelitis definitively and exclude a number of possible differential diagnoses.

Fetal cardiac tumors are often the first clinical manifestation of tuberous sclerosis (TS) when fetal ultrasound screening is performed. TS is an autosomal dominant disorder caused by the mutations in TSC1 or TSC2 genes. Here we report a case of a patient with a fetal and neonatal cardiac tumor who underwent a genetic analysis for TS after birth. Multiple fetal cardiac tumors were detected on ultrasonography at 24 weeks, gestation with no other manifestation. Neither epilepsy nor mental retardation was seen after birth. Once the parents were provided careful genetic counseling, a genetic analysis for TS was performed when the patient was 2 years old that demonstrated a novel pathogenic missense variant: c.1072T>C, p.Trp358Arg in the TSC2 gene with 30% mosaicism. This pathogenic variant is located on exon 10 of the TSC2 gene, which encodes the hamartin binding domain, leading to impair inhibitory function of the hamartin-tuberin complex, which activates mammalian target of rapamycin(mTOR) activity. The cardiac tumors were diagnosed as rhabdomyomas, a major clinical feature of TS, since the penetrance of this gene variants are thought to be 100%. We speculate that this new missense variant in TSC2 gene with 30% mosaicism will be associated to the milder phenotype of TS since the regression of the rhabdomyomas is the only manifestation in this patient. We hope that this case report might help clinicians and genetic counselors manage individualized surveillance plans for patients with TS.

Preoperative identification of the Adamkiewicz artery (AKA) with adequate reconstruction or preservation during surgery is useful for protecting the spinal cord from ischemia during thoracoabdominal aortic repair. However, the identification of the AKA remains challenging in some cases, especially with chronic aortic dissection. In a 45-year-old man with chronic aortic dissection requiring thoracoabdominal aortic repair, conventional contrast-enhanced CT or MR angiography failed to detect AKA due to the large entry tear and an enlarged false lumen. Intra-arterial ultra-high-resolution CT angiography combined with hemodynamic assessment using 4D flow MRI successfully identified the AKA, allowing for aortic repair with targeted intercostal artery reconstruction without postoperative signs of spinal cord ischemia.

We report the case of a 62-year-old male on long-term hemodialysis who was admitted to our hospital due to acute cerebral infarction associated with a cardiac calcified amorphous tumor (CAT). The patient presented with recurrent episodes of syncope and retrograde amnesia. Brain MRI identified multiple acute cerebral infarctions, while transthoracic echocardiography (TTE) revealed a 2.5 cm echogenic mobile mass attached to the ventricular side of the posterior mitral leaflet. The patient underwent surgical resection of the mass. Pathological examination confirmed the diagnosis of a CAT. A chest computed tomography (CT), performed incidentally for pneumonia 6 months prior, revealed extensive calcifications in the mass. Postinfarction imaging showed a reduction in calcifications within the mass, suggesting a potential link between the infarction and changes in the cardiac lesion.

Wilms tumor (WT) is the most common primary renal malignancy in the pediatric population and has very good overall survival with contemporary treatment protocols. In contrast, WT in adults is extremely rare and is associated with a poorer prognosis. The clinical presentation and imaging features of WT in adults are nonspecific and overlap with other more common forms of renal cancer, often leading to a delay in diagnosis. Here we describe the imaging findings of a 27-year-old female with WT initially presenting with hematuria, right lower quadrant pain and fever.

Mucinous carcinoma of the breast, also known as colloid carcinoma, is an uncommon type of differentiated adenocarcinoma, representing only 2% of all invasive breast carcinomas. It usually occurs in women ≥ 60 years of age. Mucinous carcinoma is characterized by clusters of epithelial tumour cells suspended in pools of extracellular mucin and is further divided in 2 subgroups, pure and mixed. Compared to invasive ductal carcinoma, mucinous carcinoma has a better prognosis, being characterized by a lower incidence of nodal involvement and a more favorable histological grade, with low proliferative activity and high expression of hormone receptors. Overall 10-year survival is estimated to be more than 90%. We present a case of a 57-year-old female patient who presented a palpable mass in the right breast for at least 2 years. On examination the whole breast appeared swollen, congestive and painless to palpation. Breast ultrasound, breast MRI and tru-cut biopsy were performed and suggested an advanced infiltrated carcinoma with mucinous aspects. Immunohistochemistry study demonstrated ER positivity (95%), PR low (5%), HER-2-Neu negativity (score 0) and proliferative index (Ki67) of 20%, determining a Luminal B-like (HER 2-negative) subtype. The patient was then candidated to mastectomy surgery and breast reconstruction with DIEP flap. Axillary lymp-nodes were sampled surgically.

Sclerosing angiomatoid nodular transformation (SANT) is a rare benign vascular disease and mostly discovered incidentally in asymptomatic patients. Since SANT grows over time and it is often difficult to rule out malignancy on imaging, splenectomy is frequently the treatment of choice. Image findings of SANT have been reported as low signal intensity on T2-weighted magnetic resonance (MR) images and a characteristic enhancement pattern on dynamic contrast-enhanced computed tomography (CT) and MR images. This report describes a case of a 43-year-old woman with SANT presenting multiple calcifications on CT images, and discusses the characteristics and mechanism of the calcification, while reviewing previously reported cases of SANT.

Diffuse-type giant cell tumor of the tendon sheath (GCTTS) is a rare, benign, yet locally aggressive soft tissue tumor commonly affecting the hand. This case report presents a 55-year-old male with a 5-year history of GCTTS in the flexor tendon sheath of the long finger. MRI played a critical role in both diagnosis and surgical planning, revealing key features such as the tumor's 10 cm length, hemosiderin deposition, and blooming artifacts. The patient underwent successful surgical excision with no recurrence at the 1-year follow-up. This case underscores the significance of MRI in preventing functional impairment and reducing recurrence risk in diffuse-type GCTTS.

Transient osteoporosis (TO) is a self-limiting bone disorder with a benign clinical course and unknown etiology, typically manifesting in the third trimester of pregnancy. There are only a few documented cases of TO in pregnant women involving the knee joint. We report a 38-year-old female patient in the third trimester of pregnancy who presented with an 8-week history of progressive worsening of the right knee pain. Clinical and magnetic resonance imaging findings were suggestive of TO with complete resolution of symptoms and imaging findings within several months following the onset of the symptoms. Clinicians need to include TO in their differential diagnosis when treating pregnant women with knee pain.

Background: Studies have revealed that anterior glenoid rim bone resorption occurs in the early stage after arthroscopic Bankart repair (ABR) if bony Bankart lesions are absent or fail to heal. However, this structural change has never been studied after repair by footprint fixation (FF). Additionally, the relationship between the extent of rim resorption and healing of the repaired capsulolabral complex (CLC) remains unclear. Therefore, this study aimed to investigate anterior glenoid rim changes after ABR by FF and to elucidate the correlation between rim resorption and the healing of the repaired CLC. Methods: This was a retrospective study on shoulders that underwent ABR by a combination of knotless twin anchor FF and single row techniques for anterior shoulder instability from January 2022 to June 2023. From 44 shoulders, we included 23 after excluding 14 with preoperative bony Bankart lesions and 7 with missing postoperative imaging. We used 3-dimensional computed tomography scans to calculate the change in glenoid width (Δ%) due to anterior glenoid rim change from baseline to 3 months postoperatively and images from magnetic resonance arthrography, which was performed at around 5 months postoperatively, to evaluate CLC healing according to a 3-point grading scale (good, 3 points; fair, 2 points; poor, 1 point) on 6 oblique axial slices perpendicular to the glenoid long axis. Finally, we calculated the correlation coefficient between Δ% and the healing index, that is, the mean CLC healing grade of the 6 slices. Results: Glenoid width decreased by 7.2% (range, 2.0%-12.8%; P < .001). The mean CLC healing index was 2.59 points (range, 1.8-3.0). The Δ% showed a moderate positive correlation with the healing index (correlation coefficient, 0.55; P = .006). Conclusion: Anterior glenoid rim resorption also occurs after ABR by the combination of FF and single row technique at 3 months postoperatively. Although this is a preliminary result, the extent of rim resorption is greater with better healing of the repaired CLC.

A 34-year-old woman (gravida 2, para 0) with suspected fetal small-bowel atresia on ultrasound underwent magnetic resonance imaging (MRI) at 33 weeks 3 days of gestation. In addition to small bowel atresia, a teardrop-shaped hematoma was observed adjacent to the umbilical cord associated with an umbilical cord ulcer (UCU). The fetus was delivered by induced labor on diagnosis of intrauterine fetal death. UCUs were macroscopically observed on the surface of the umbilical cord. Ultrasonography is helpful in the diagnosis of UCU. Moreover, the MRI findings on UCUs adjacent to the umbilical cord in the case of congenital small bowel atresia should be observed carefully, especially after 30 weeks of gestation. MRI findings may lead to the detection of UCU and improve fetal outcome. Therefore, we should be aware of its findings.

We present the case of a 22-year-old male with a left adrenal pheochromocytoma, initially diagnosed during a workup for thoracic pain. The patient's tumor was refractory to medical management, and surgical resection was ruled out due to high cardiovascular risk, stemming from cyanotic congenital heart disease, aortic aneurysm, and factor VII deficiency. The patient underwent adrenal artery embolization (AAE) as a salvage treatment. Following the procedure, there was an initial reduction in hypertensive crises and biochemical markers, with plasma normetanephrine levels decreasing from 1490 pg/mL to 313 pg/mL. However, over subsequent months, the patient experienced symptom recurrence, and biochemical relapse occurred, with normetanephrine levels rising to 742 pg/mL by 3 months postprocedure. This case highlights the potential for AAE to provide short-term symptom relief and biochemical response; nevertheless, it may not be an effective long-term curative option. More collaborative and prospective studies are needed to assess its success and efficacy.

Renal fusion anomalies are rare congenital malformations that comprise horseshoe kidney and crossed fused ectopia. Renal tumors arising from these fusion anomalies are anatomically complex, and surgical management can be technically challenging because of altered renal anatomy. Percutaneous CT-guided ablation can overcome some of these anatomical constraints, and microwave ablation has the additional benefit of shorter treatment time and reduced sensitivity to heat sink effects compared to other ablative modalities. The present report describes the successful use of microwave ablation to treat renal cell carcinoma arising in a horseshoe kidney with no local recurrence after 4.5 years, demonstrating the feasibility of MWA in managing RCC in anatomically complex locations.

This case report presents a clinical case of management of a patient with concomitant ischemic stroke and acute arterial ischemia of the right upper limb. Emergency thrombaspiration from the middle cerebral artery improved the patient's neurological status. A hybrid intervention was carried out to restore blood flow in the right upper limb: brachial artery arteriotomy with thrombectomy through an open approach combined with endovascular recanalisation and balloon angioplasty of the forearm arteries. The comprehensive approach, incorporating endovascular and traditional vascular surgery techniques, resulted in a successful clinical outcome and avoided serious complications. This case highlights the importance of a multidisciplinary approach and timely intervention in treating complex cardiovascular pathologies.

Janus kinase (JAK) inhibitors block pathways involved in inflammation and immune response, making JAK inhibitors useful in the treatment of various diseases. While the efficacy of these drugs has been proven in several studies, their safety profile needs to be further investigated. In this systematic review and meta-analysis, we examined the risk of infections during treatment with oral JAK inhibitors with no concomitant treatment compared to placebo in phase 2 and 3 randomized, placebo-controlled trials. The medical databases PubMed, Web of Science, and EMBASE were searched from inception through February 2024, yielding 13,567 nonduplicate articles, of which 69 were included in the final quantitative analysis. Overall, we found that treatment with oral JAK inhibitors was associated with an increased risk of infections compared to placebo across all indications (relative risk: 1.39 [95% CI: 1.096-1.76, P = .0067]) and in dermatologic indications (relative risk: 1.46 [95% CI, 1.10-1.93, P = .0097]). Remarkably, an increased risk of herpes zoster infections was found in dermatologic indications but not in nondermatologic indications. In conclusion, we identified a significantly increased risk of developing infections during treatment with oral JAK inhibitors compared to placebo across indications. In sub-analyses, we additionally found an increased risk of herpes zoster in dermatologic indications.

Background: Little is known about the dermatologic manifestations of multisystem inflammatory syndrome in children (MIS-C) in children and adolescents. Objective: We sought to describe the demographic background, key clinical features, and the clinical consequences of developing rash manifestations in MIS-C patients at Texas Children’s Hospital. Methods: Descriptive retrospective cohort study of 290 hospitalized eligible patients between May 2020 and April 2022. Results: Among MIS-C patients, 51% exhibited a rash. We found that younger children (8.62 vs 9.49 years of age, P = .006) and White children (P = .002) had a higher likelihood of developing a rash in association with MIS-C. Additionally, patients without a rash had increased maximum troponin levels (0.11 ng/mL vs 0.07 ng/mL, P = .02) and a higher incidence of cardiac involvement (83.1% vs 72.3%, P = .03) compared to those with a rash but did not significantly affect the length of hospital stay or clinical course. The most commonly observed rash was an erythematous and maculopapular rash on the trunk and/or extremities. Limitations: Rash characteristics were initially described by a variety of physicians in the pediatric primary care services. Conclusion: Rash manifestations in MIS-C patients are associated with lower cardiac involvement and decreased troponin levels.

A 62-year-old man was referred to our hospital presenting with a sore throat, dyspnea, and cervical swelling. Initial precontrast CT scans revealed a cervical and mediastinal hematoma, along with a hemothorax. Further dynamic contrast-enhanced CT scans indicated contrast media extravasation dorsal to the right thyroid gland lobe, suggesting a rupture of the right inferior thyroid artery or a parathyroid adenoma. Following endotracheal intubation, angiography confirmed extravasation from the right inferior thyroid artery. Transarterial embolization (TAE) was successfully performed using a gelatin sponge. The cervical and mediastinal hematoma were surgically excised, and the right inferior parathyroid gland was simultaneously resected. Pathological examination revealed no neoplastic components.

Background: Molluscum contagiosum (MC) is a contagious viral skin infection. Berdazimer gel, 10.3% (SB206 12%) is approved in the United States as the first topical, at-home MC prescription medication. Objective: To assess safety and tolerability of SB206 12% in Japanese patients with MC. Methods: SKN15B01 (JRCT2031230123) was a phase 2, multicenter, single-group, open-label study in Japanese patients ≥2 years old with 3-70 baseline MC lesions. Patients with only periocular MC and/or immunosuppression were excluded. SB206 12% was applied once daily to lesions for 12 weeks. Safety endpoints included adverse events and local skin reactions. Exploratory efficacy endpoints included percentage of patients with complete lesion clearance and lesion count percent change from baseline. Results: Twenty patients (12 males, 8 females) with mean (range) age of 5.2 (3-13) years and mean (range) baseline lesion counts of 22.5 (8-44). Complete clearance and percent change from baseline at week 12 were 60% and −89.2%, respectively. The most common treatment-related adverse events were application site-erythema (25%, n = 5), -pain (25%, n = 5), -pruritis (25%, n = 5), and -dermatitis (20%, n = 4), all mild/moderate in severity. Limitations: Single-group study; small sample size. Conclusion: Safety and efficacy of berdazimer gel, 10.3% in Japanese patients were favorable and consistent with previous studies.

Background: The gut-skin-brain axis has been long postulated in acne vulgaris. Few studies focused on bowel habits in patients with acne vulgaris have yielded controversial results. Objectives: To examine the relationship between acne vulgaris and gastrointestinal comorbidities. Methods: We conducted a nationwide case-control study using data from the Taiwan National Health Insurance Research Database spanning the years 1997 to 2013. Acne vulgaris and the control group were stratified by age, and we examined the association of gastrointestinal comorbidities across different age, sex, and antibiotic use through conditional logistic regression analysis. Results: A total of 185,491 patients with acne vulgaris were identified. The primary demographic for acne vulgaris comprised adolescents, followed by adult-onset groups, with a female predominance observed across all age subgroups. Patients with acne vulgaris exhibited a significantly elevated risk of developing gastrointestinal comorbidities, including peptic ulcers, irritable bowel syndrome, gastroenteritis, gastroesophageal reflux disease, and constipation. This increased risk was particularly notable in patients aged ≥12 years, and those with moderate-to-severe acne. Limitations: Miscoding and misclassification might have occurred. Conclusions: Patients with Acne vulgaris have higher risks of gastrointestinal comorbidities. For patients with moderate-to-severe acne, gastroenterology specialty consultation may be warranted.

Background/Objective: Individuals with X-linked hypophosphatemia (XLH) generally experience normal puberty. However, the prevalence of central precocious puberty (CPP) in patients with XLH seems to be similar to that of the general population, and CPP may similarly impact their predicted final height. Case Report: A female patient was diagnosed with XLH at 3 years old and received regular calcitriol and sodium-potassium phosphate treatment until age six. During this period, she showed increased growth velocity and improved height Z-score (from −2.38 SD to −1.95 SD). At 6 years and 11 months, she was diagnosed with idiopathic CPP, marked by thelarche, a growth spurt, and advanced bone age, resulting in a decreased predicted final height Z-score. She began pubertal blockade with leuprolide acetate and transitioned from conventional XLH treatment to burosumab. The combination of these treatments led to stabilized bone age, normalized growth velocity, and improved final height prediction without side effects or negative impacts on bone health during treatment. Discussion: Although the prevalence of CPP in XLH patients has not been extensively studied, CPP in XLH may affect final height and worsen rickets by increasing mineral demands during growth spurts. Thus, CPP can be treated in patients with XLH, who may have compromised height outcomes, using synthetic gonadotropin-releasing hormone analogs. Conclusion: In the described XLH patient with CPP, the combined use of gonadotropin-releasing hormone analogs and burosumab was a safe strategy to stabilize pubertal progression and bone age, minimize anthropometric loss, and avoid exacerbating bone deformities.

Background: Heart failure should be diagnosed as early as possible. Although deep learning models can predict one or more echocardiographic findings from electrocardiograms (ECGs), such analyses are not comprehensive. Objectives: This study aimed to develop a deep learning model for comprehensive prediction of echocardiographic findings from ECGs. Methods: We obtained 229,439 paired ECG and echocardiography data sets from 8 centers. Six centers contributed to model development and 2 to external validation. We identified 12 echocardiographic findings related to left-sided cardiac abnormalities, valvular heart diseases, and right-sided cardiac abnormalities. These findings were predicted using convolutional neural networks, and a composite label was analyzed using logistic regression. A positive composite label indicated positivity in any of the 12 findings. Results: For the composite findings label, the area under the receiver-operating characteristic curve was 0.80 (95% CI: 0.80-0.81) on hold-out validation and 0.78 (95% CI: 0.78-0.79) on external validation. The composite findings label applying logistic regression had an area under the receiver-operating characteristic curve of 0.80 (95% CI: 0.80-0.81) with accuracy of 73.8% (95% CI: 73.2-74.4), sensitivity of 81.1% (95% CI: 80.5-81.8), and specificity of 60.7% (95% CI: 59.6-61.8). Conclusions: We have developed convolutional neural network models that predict a wide range of echocardiographic findings, including left-sided cardiac abnormalities, valvular heart diseases, and right-sided cardiac abnormalities from ECGs and created a model to predict a composite findings label by logistic regression analysis. This model has potential to serve as an adjunct for early diagnosis and treatment of previously undetected cardiac disease.

Background: Pericoronary adipose tissue attenuation (PCATA) is a novel imaging biomarker of pericoronary inflammation associated with coronary artery disease. Several studies have reported the usefulness of PCATA among people of European ethnicity; however, data are lacking concerning those of Asian ethnicity. Objectives: This multicenter study aimed to evaluate the effect of PCATA on prognosis in East Asian patients. Methods: Between August 2011 and December 2016, 2,172 patients underwent clinically indicated coronary computed tomography angiography (CTA) at 4 hospitals in Japan. Among them, 1,270 patients were analyzed. PCATA was evaluated using coronary CTA to measure pericoronary adipose tissue density surrounding the 3 major coronary arteries. The outcomes were composite cardiovascular events, including cardiovascular death and acute coronary syndrome; 33 cardiovascular events observed during a median follow-up of 6.0 years (Q1-Q3: 3.6-8.2 years). Results: Right coronary artery (RCA)-PCATA was significantly higher in patients with cardiovascular events than in those without (−63.7 ± 8.9 HU vs −67.4 ± 9.1 HU, respectively; P = 0.021). High RCA-PCATA was significantly associated with cardiovascular events in a model that included the Hisayama risk score and adverse coronary CTA findings (HR: 1.55; 95% CI: 1.07-2.24; P = 0.019). Conclusions: High RCA-PCATA showed significant association with future cardiovascular events after adjusting conventional risk factors and adverse coronary CTA findings in East Asian patients who underwent clinically indicated coronary CTA.

Background: Coronary physiology measured by fractional flow reserve (FFR) is superior to angiography for assessing the efficacy of percutaneous coronary intervention (PCI). Yet, the clinical adoption of post-PCI FFR is limited. Murray law-based quantitative flow ratio (μQFR) may represent a promising alternative, as it can quickly compute FFR from a single angiographic view. Objectives: The authors aimed to investigate the potential role of post-PCI μQFR in predicting clinical outcomes. Methods: This was a post hoc blinded analysis of the FLAVOUR trial. Patients with angiographically intermediate lesions randomized 1:1 to receive FFR or intravascular ultrasound-guided PCI were included. Post-PCI μQFR was assessed in successfully stented vessels, blinded to clinical outcomes. Suboptimal physiological outcome post-PCI was defined a priori as post-PCI μQFR

Background: Elevated blood pressure (BP) in childhood is associated with adult hypertension and arterial stiffness. However, the effect of long-term time in target range (TTR) for BP since childhood on the risk of arterial stiffness in midlife remains unclear. Objectives: The purpose of this study was to determine the independent association of TTR for systolic blood pressure (SBP) from childhood to midlife with arterial stiffness in adulthood. Methods: This study used data from the ongoing cohort of the Hanzhong Adolescent Hypertension Study. SBP-TTR was assessed over 36 years, with the target ranges of SBP defined as the 90th to 95th percentile of SBP for age, sex, and height in childhood, and 110 to 130 mm Hg in adulthood. Arterial stiffness was defined as brachial-ankle pulse wave velocity >1,400 cm/s. Results: Of the total 1,959 participants, 55.5% (1,088 of 1,959) were men, and the mean age was 49 years. The risk of arterial stiffness exhibited a gradual decrease with increasing SBP-TTR over the 36-year follow-up. Compared with the participants in the lowest quartile of SBP-TTR from childhood to midlife, those in the highest quartile showed significantly reduced arterial stiffness risk in midlife. This association persisted even after adjusting for mean SBP and SBP variability. Furthermore, men in the highest quartile of SBP-TTR demonstrated a markedly lower arterial stiffness risk than those in the lowest quartile, whereas this effect was not observed in women. Conclusions: Higher long-term SBP-TTR from childhood to midlife is associated with a reduced risk of arterial stiffness in midlife, regardless of the mean SBP or SBP variability.

Background: The Genoss paclitaxel-coated balloon (PCB) is a novel PCB with shellac and vitamin E as excipients, enhancing drug delivery to the target lesion and minimizing restenosis. Objectives: This study aimed to compare quantitative coronary angiographic outcomes at 6 months after treatment of de novo coronary artery disease (CAD) with 2 different types of PCBs. Methods: This prospective, multicenter, noninferiority trial randomized 204 patients with chronic coronary syndrome or stabilized acute coronary syndrome to treatment with the shellac and vitamin E-based PCB or the reference PCB (SeQuent Please NEO) in a 1:1 ratio. The primary endpoint was noninferiority for the 6-month angiographic in-lesion late lumen loss. Results: The 6-month in-lesion late lumen loss was 0.06 ± 0.38 mm with shellac and vitamin E-based PCB vs 0.09 ± 0.36 mm with reference PCB. The 1-sided 97.5% upper confidence limit of the difference was 0.08 mm, which was lower than the noninferiority limit of 0.15 mm, achieving noninferiority (P for noninferiority = 0.001). There was comparable late lumen enlargement (44.7% vs 42.7%; P = 0.903) and binary restenosis rates (3.2% vs 6.7%; P = 0.442) following treatment with shellac and vitamin E-based PCB and reference PCB, respectively. Both PCBs had similar 12-month rates of target vessel failure (3.0% in shellac and vitamin E-based PCB vs 4.3% in reference PCB; P = 0.921). Conclusions: The Genoss PCB, formulated with shellac and vitamin E as excipients, demonstrated angiographic outcomes comparable to a clinically proven PCB in the treatment of de novo CAD. (Compare the Safety and Efficacy of Genoss® DCB and SeQuent® Please NEO in Coronary De Novo Lesions; NCT05096442)

Background: Rotator cuff tears are divided into complete and partial tears, and partial rotator cuff tears include articular-sided tears and bursal-sided tears. Tears are caused by extrinsic, intrinsic, or traumatic factors; however, the mechanisms by which partial tears occur remain unknown. Recent reports have described the correlation between acromial morphology and rotator cuff tears. To date, no reports have investigated acromial morphology in partial tears. The purpose of this study is to evaluate the incidence of abnormal acromial morphology in both partial articular-sided and bursal-sided rotator cuff tears. Methods: Patients with supraspinatus tendons that had articular-sided tears were categorized into Group A, and patients who had bursal-sided tears were categorized into Group B. Patients who underwent arthroscopic rotator cuff repair for rotator cuff tears were assessed based on their diagnosis of Group A or Group B according to arthroscopic findings. The following items were examined: age, sex, presence of diabetes mellitus, acromiohumeral distance (AHD), critical shoulder angle (CSA), lateral acromial angle (LAA), sagittal and coronal morphologies of the acromion, and traumatic shoulder tears. Results: There were 39 patients in Group A and 95 patients in Group B. A significantly greater rate of presence of diabetes was found in the Group A. There were no significant differences in age, sex, or frequency of traumatic shoulder tears. The mean AHD, CSA, and LAA in Group A and Group B were as follows: AHD, 9.4 ± 1.5 and 9.3 ± 1.4 mm; CSA, 32.1 ± 4.6 and 35.3 ± 4.4 degrees; LAA, 82.2 ± 7.2 and 79.9 ± 7.0 degrees. There were no significant differences between the groups. Although the CSA was significantly greater in Group B, there was no significant difference in the AHD or LAA. There was no significant difference in sagittal acromial morphology; however, Group B had significantly more inferior osteophytes of the acromial center in the coronal plane. Conclusion: Group B was found to have a significantly larger mean CSA compared to Group A. Group B occurred more often in patients with inferior osteophytes of the acromial center on the acromion, suggesting the involvement of extrinsic factors.