Search

Background: Cardiac papillary fibroelastomas (CPFs) are benign endocardial tumours with embolic potential. This article is a systematic review to identify the clinical profile, diagnosis, tumour characteristics, and treatment modalities in patients with CPF presenting with stroke or transient ischemic attack (TIA). Methods: This systematic review was conducted using the PubMed and Embase databases, including case reports and/or series and observational studies (for a search period of up until April 2022). A descriptive summary of case reports and/or series, and a narrative summary of observational studies, were completed. Results: A total of 161 cases were identified from 133 case reports and 11 case series. The mean age of patients was 54.8 years, and 46.6% were male. TIA and stroke were reported in 32.3% and 67.8%, respectively. The most common stroke territory was multiple brain sites (36.6%). The mean tumour size was 11.8 mm. Most of the tumours were left-sided (98.7%). The mitral valve was the most involved valve (38.9%), with the anterior leaflet being the commonest site (61.3%). A total of 91.4% of tumours were independently mobile; 10.6% of tumours missed by transthoracic echocardiography were identified on transesophageal echocardiography. Antiplatelet and anticoagulation treatment were used in 87.9% and 12.1% of cases, respectively. Simple excision, valve repair, and valve replacement were performed in 66.7%, 16.7%, and 16.7%, respectively. The logistic regression model revealed that age was the only significant predictor; an increase in the log-odds of recurrent cerebrovascular events occurred with increasing age. Conclusions: CPFs are a differential diagnosis of cryptogenic stroke, especially if the initial workup for stroke is negative. Transesophageal echocardiography serves as a better imaging tool, compared to transthoracic echocardiography, in identifying CPF. Although the consensus for CPF management remains controversial, surgical excision is the primary approach for left-sided CPF presenting as stroke or TIA. Résumé: Contexte: Les fibroélastomes papillaires cardiaques (FPC) sont des tumeurs endocardiques bénignes pouvant provoquer une embolie. Cet article est une revue systématique visant à définir le profil clinique, le diagnostic, les caractéristiques tumorales et les modalités de traitement chez les patients atteints de FPC qui subissent un accident vasculaire cérébral (AVC) ou un accident ischémique transitoire (AIT). Méthodologie: Cette revue systématique a été menée à partir des bases de données PubMed et Embase, comprenant des rapports et/ou séries de cas et des études observationnelles (la période couverte allait jusqu’à avril 2022). Un résumé descriptif des rapports et/ou séries de cas et un résumé narratif des études observationnelles ont été rédigés. Résultats: Au total, 161 cas ont été retenus sur 133 rapports de cas et 11 séries de cas. L’âge moyen des patients était de 54,8 ans, et 46,6 % étaient des hommes. Des AIT et des AVC ont été signalés chez respectivement 32,3 % et 67,8 % des patients. Le territoire infarci regroupait le plus souvent de multiples sièges cérébraux (36,6 %). La taille moyenne des tumeurs était de 11,8 mm. La plupart des tumeurs (98,7 %) se trouvaient du côté gauche. La valve mitrale était la valve la plus atteinte (38,9 %), le feuillet antérieur étant le foyer le plus fréquent (61,3 %). Au total, 91,4 % des tumeurs étaient mobiles de manière indépendante; 10,6 % des tumeurs non décelées par échocardiographie transthoracique ont été détectées par échocardiographie transœsophagienne. Des traitements antiplaquettaires et anticoagulants ont été utilisés chez respectivement 87,9 % et 12,1 % des cas. Une excision simple, une réparation de la valve et un remplacement de la valve ont été réalisés chez respectivement 66,7 %, 16,7 % et 16,7 % des cas. Le modèle de régression logistique a révélé que l’âge était le seul facteur prédictif important; le ratio « log-odds » des événements cérébrovasculaires récurrents a augmenté avec l’âge. Conclusions: Les FPC constituent un diagnostic différentiel de l’AVC cryptogénique, particulièrement si l’examen initial pour l’AVC a donné un résultat négatif. L’échocardiographie transœsophagienne est un meilleur outil d’imagerie que l’échographie transthoracique pour déceler les FPC. Bien que le consensus pour le traitement des FPC demeure controversé, l’excision chirurgicale est la principale technique pour les FPC du côté gauche qui se manifestent sous la forme d’un AVC ou d’un AIT.

Cobblestone lissencephaly (C-LIS) (TYPE II) is a rare and severe neuronal migration disorder characterized by a smooth brain surface with overmigrated neurons and abnormal formation of cerebral convolutions or gyri during fetal development, resulting in a cobblestone appearance. C-LIS is associated with eye anomalies and muscular dystrophy. This case report presents a detailed clinical and neuroimaging analysis of a patient diagnosed with cobblestone lissencephaly (Type II). It reviews pertinent literature to enhance our understanding of this complex condition. We report a case of a 6-year-old female child with cobblestone lissencephaly (C-LIS) (Type II) severe developmental delays, hypotonia, and recurrent intractable seizures. Magnetic resonance imaging (MRI) revealed a characteristic cobblestone appearance on the brain surface, indicative of abnormal neuronal migration. In addition to the classic findings of Type II Cobblestone lissencephaly, the patient displayed ventriculomegaly and cerebellar hypoplasia, contributing to the overall neurological impairment observed. The literature review highlights the genetic basis of cobblestone lissencephaly, emphasizing the involvement of genes associated with glycosylation processes and basement membrane integrity. Neuroimaging findings, including MRI and computed tomography scans, are crucial for accurate diagnosis and prognostication. Early identification of cobblestone lissencephaly allows for appropriate counseling and management strategies. However, the prognosis remains guarded, and interventions primarily focus on supportive care and seizure management. This case report contributes to the knowledge of cobblestone lissencephaly, shedding light on the clinical spectrum and neuroimaging features associated with this rare disorder. To clarify the underlying genetic mechanisms and possible therapeutic pathways for better patient outcomes, more investigation is necessary.

Pseudoaneurysm development is a well-recognized consequence of arterial injury, frequently observed in procedures involving arterial groin access. Breast emergencies are infrequent but need prompt attention. We present a notable case of breast pseudoaneurysm postcore needle biopsy, incidentally, identified through subsequent magnetic resonance imaging. Remarkably, the patient's lactating status emerged as a unique risk factor. Our report thoroughly explores the pathogenesis, etiology, preventive measures, and treatment strategies specific to breast pseudoaneurysms. A comprehensive understanding of this phenomenon is essential for radiologists at large, with particular importance for specialists in breast imaging.

Multifocal nodular hepatic steatosis (MFNHS) is a rare benign clinical entity mimicking metastatic disease. This study is designed to describe the imaging and histopathologic findings and clinical course of patients with MFNHS. In this retrospective study during 2005 and 2023, 10 patients with an imaging and pathologic diagnosis of MFNHS were included. The imaging and histopathology findings were reviewed in each case. The follow-up images were reviewed to assess the clinical course of the disease. The mean age was 50.0 ± 10.5 years, and the male-to-female ratio was 4:6. Three patients had a past medical history of cancer. All patients were found to have lesions suspicious of malignancy on either ultrasound (US) or computed tomography (CT) requiring further workup. Six patients underwent magnetic resonance imaging (MRI), and 4 patients underwent an image-guided biopsy which resulted in hepatic steatosis. During the follow-up period, the majority of patients (71.5%) remained unchanged or improved, while 2 patients (28.5%) progressed. MRI is a reliable modality in detecting and characterizing MFNHS and should be considered to further assess multiple hepatic lesions in cases where the clinical suspicion is not high for metastasis.

Background: Combined heart-liver transplantation (CHLT) is a complex procedure with rising demand and is subject to ongoing assessment. Here, we provide an update on indications, patient outcomes, and risk factors. Methods: This retrospective study utilized CHLT data from the United Network for Organ Sharing registry between 1990 and 2023. Recipient and donor characteristics, and risk factors for mortality were analyzed using Cox regression hazard models. Recipient and graft survival at 30 days, 1 year, and 5 years were analyzed using the Kaplan-Meier method. Results: This cohort included 532 patients with median survival of 16.9 years (SD: 1.09). The most common indications for CHLT were congenital heart disease (36%) and dilated cardiomyopathy (31%). Patient survival at 30 days, 1 year, and 5 years were 94%, 85%, and 77%, respectively. Combined heart-liver graft survival was 93%, 85%, and 77%, respectively. Diabetes (hazard ratio [HR]: 1.74; p = 0.04) was associated with multigraft failure and mortality in multivariate analysis. Compared to congenital heart disease, dilated (HR: 0.55; p = 0.03) and restrictive myopathies (HR: 0.5; p = 0.03) were associated with improved graft and overall survival. Higher donor left ventricular ejection fraction (EF) was also associated with improved graft and overall survival (HR: 0.96; p = 0.008). Conclusions: CHLTs are being performed at increasingly higher rates with comparable survival to single-organ transplants. Diabetes was associated with increased mortality. Recipient dilated or restrictive myopathies and higher donor EF were correlated with improved survival compared to congenital heart disease. Further studies are needed to better understand these observations.

Clostridium paraputrificum is a gram-positive anaerobic spore-forming bacillus with a pathological prevalence of

Endovascular stents are predominantly utilized for intra-arterial interventions; however, their application in managing venous injuries, especially traumatic ones, lacks comprehensive guidelines and long-term outcome studies. This case report discusses the innovative deployment of an infrarenal inferior vena cava stent for a traumatic inferior vena cava injury after a gunshot wound in a polytrauma patient. This case aims to enhance the existing evidence on the feasibility and potential outcomes of endovascular stenting in traumatic venous injuries.

Fetus-in-fetu (FIF) is a rare congenital anomaly in which a malformed parasitic twin develops within the body of a live fetus or child. Abdominal teratoma, a type of germ cell tumor, can be a great imaging mimicker of FIF and vice-versa, as they both can present as a heterogeneous mass with calcifications and a fat component. Radiological differentiation of these 2 entities should be made because of the difference in surgical planning and treatment options. Features such as visualization of distinct bony vertebral elements and encysted cystic components are the specific features of Fetus in fetu [1]. In contrast, the presence of elevated serum markers can help diagnose teratoma. Here, we report a case of a 5-month-old girl presented with progressive distension of the upper abdomen for the last 2 months, noticed by her mother. Her initial imaging with abdominal X-ray and ultrasonography showed the presence of a large heterogenous solid-cystic mass in the upper abdomen with large elongated calcifications. A provisional diagnosis of teratoma vs FIF was considered. CECT abdomen showed clear identification of osseous structures of the axial and appendicular skeleton within a fat density mass, along with an encapsulated cystic component, strongly suggestive of FIF. Her serum tumor markers were within normal limits. The final diagnosis of FIF was confirmed on Laparotomy and postoperative specimens.

Background: Severe burns can significantly impact various organ systems, including the gastrointestinal (GI) system. GI complications are frequently observed in patients with over 20% total body surface area (TBSA) burn. Objectives: This case series delves into the intricate phenomenology of post-burn GI dysfunction, challenging conventional cause-and-effect paradigms. Our aim is to discern, comprehend, and explore variables influencing positive and negative outcomes, laying the foundation for further research given the current heterogeneity in the literature. Methods: Severe burn patients with GI dysfunction identified between April 1, 2022, and July 31, 2022, from the institutional database are included in this retrospective case-series, and comparisons were made across baseline and treatment conditions across participants. Data were collected on demographics, burn characteristics, complications, and treatment outcomes. Results: We analysed 12 patients with severe burns and GI dysfunction and categorized them into two patterns: Pattern A, characterised by early onset symptoms, gastric and small bowel dilatation, and a relatively benign course with high recovery rates was observed in 6 patients; and Pattern B, characterised by late-onset symptoms, colonic dilatation, shock, and a high mortality rate due to megacolon was seen in 6 patients. Conclusion: The post-burn GI dysfunction observed in our study is a complex interplay of multiple factors. Adequate fluid resuscitation, timely excision of necrotic tissue, staged food ingestion, specific nutrient administration, and appropriate use of antibiotics and judicious use of selective digestive decontamination (SDD) are essential strategies to prevent and treat this syndrome.

Fusobacterium nucleatum is a commensal pathogen typically found in the oral cavity, digestive tract, and urogenital system which has been associated with Lemierre’s syndrome, periodontal diseases, sinusitis, endocarditis, and intra-abdominal and brain abscesses. Our case is of a 62-year-old male who presented with headaches, nausea, and vision loss. Brain imaging identified a right occipito-parietal brain abscess. Following surgery and abscess drainage, Fusobacterium nucleatum was isolated from intraoperative cultures, and the infectious disease service was consulted for antibiotic recommendations. Additional history uncovered that he had also been experiencing night sweats, generalized weakness and 40-pound weight loss for 2 months, and had a prior history of colon polyps and diverticulitis. Furthermore, the patient disclosed having substandard oral hygiene practices, particularly in relation to the care of his dental appliances. Despite negative blood cultures, suspicion for hematogenous seeding was high. Imaging ruled out periodontal disease, but identified a colovesical fistula and liver abscesses, indicating potential translocation of bacteria via portal circulation to his liver. Echocardiogram workup revealed a 1-cm mobile vegetation on the aortic valve. His course was complicated by breakthrough seizures, renal failure, and drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, and he ultimately completed 16 weeks of antibiotics. This case illustrates an uncommon presentation of brain abscess in an immunocompetent adult, with a prior episode of diverticulitis as the probable primary infection source, leading to development of a colovesical fistula and bacterial dissemination to the liver, heart, and brain. It highlights the importance of a comprehensive diagnostic approach, including consideration of atypical pathogens in immunocompetent adults.

Background: Severe cutaneous adverse reactions (SCAR) are a group of delayed presumed T-cell mediated hypersensitivities associated with significant morbidity and mortality. Despite their shared global healthcare burden and impact, the clinical phenotypes, genomic predisposition, drug causality, and treatment outcomes may vary. We describe the establishment and results from the first Australasian registry for SCAR (AUS-SCAR), that via a collaborative network advances strategies for the prevention, diagnosis and treatment of SCAR. Methods: Prospective multi-center registry of SCAR in Australian adult and adolescents, with planned regional expansion. The registry collects externally verified phenotypic data drug causality, therapeutics and long-term patient outcomes. In addition, biorepository specimens and DNA are collected at participating sites. Results: we report on the first 100 patients enrolled in the AUS-SCAR database. DRESS (50%) is the most predominant phenotype followed by SJS/TEN (39%) and AGEP (10%), with median age of 52 years old (IQR 37.5, 66) with 1:1 male-to-female ratio. The median latency for all implicated drugs is highly variable but similar for DRESS (median 15 days IQR 5,25) and SJS/TEN (median 21 days, IQR 7,27), while lowest for AGEP (median 2.5 days, IQR 1,8). Antibiotics (54.5%) are more commonly listed as primary implicated drug compare with non-antibiotics agent (45.5%). Mortality rate at 90 days was highest in SJS/TEN at 23.1%, followed by DRESS (4%) and AGEP (0%). Conclusion: In the first prospective national phenotypic and biorepository of SCAR in the southern hemisphere we demonstrate notable differences to other reported registries; including DRESS-predominant phenotype, varied antibiotic causality and low overall mortality rate. This study also highlights the lack of standardised preventative pharmacogenomic measures and in vitro/in vivo diagnostic strategies to ascertain drug causality. Trial registration: ANZCTR ACTRN12619000241134. Registered 19 February 2019.

In this paper, we present a detailed case study from our transplant evaluation clinic, focusing on a postpartum patient with end-stage heart and kidney failure being considered for heart transplantation. The evaluation revealed pituitary dysfunction, correlating with Sheehan syndrome, a condition arising from significant blood loss that leads to pituitary gland hypoperfusion and necrosis. This diagnosis is particularly noteworthy considering the pituitary gland's vital role in hormonal regulation, which impacts multiple organ systems. The gland's vulnerability to ischemia, especially due to its enlargement during pregnancy, is a critical factor. Our case highlights the necessity of thorough pretransplant evaluations to identify reversible endocrine factors contributing to organ failure, emphasizing the complex interplay between endocrine health and organ transplant suitability. This study serves as an important reminder for clinicians to consider endocrine causes in transplant candidates, especially in postpartum patients.

Women are disproportionately affected by symptoms of angina with nonobstructive coronary arteries (ANOCA) which is associated with significant mortality and economic impact. Although distinct endotypes of ANOCA have been defined, it is underdiagnosed and is often incompletely characterized when identified. Patients are often unresponsive to traditional therapeutic options, which are typically antianginal, and the current ability to guide treatment modification by specific pathways is limited. Studies have associated specific genetic loci, transcriptomic features, and biomarkers with ANOCA. Such panomic data, in combination with known imaging and invasive diagnostic techniques, should be utilized to define more precise pathophysiologic subtypes of ANOCA in women, which will in turn help to identify targeted, effective therapies. A precision medicine-based approach to managing ANOCA incorporating these techniques in women has the potential to significantly improve their clinical care.

Introduction: Suboptimal cardiovascular health is associated with adverse pregnancy outcomes and long-term cardiovascular risk. The authors examined trends in cardiovascular risk factors and correlates of suboptimal cardiovascular risk profiles among reproductive-aged U.S. women. Methods: With data from 335,959 women in the Behavioral Risk Factor Surveillance System (2015–2020), the authors conducted serial cross-sectional analysis among nonpregnant reproductive-aged women (18–44 years) without cardiovascular disease who self-reported information on 8 cardiovascular risk factors selected on the basis of Life's Essential 8 metrics. The authors estimated the prevalence of each risk factor and suboptimal cardiovascular risk profile (≥2 risk factors) and examined trends overall and by age and race/ethnicity. Using multivariable Poisson regression, the authors assessed the sociodemographic correlates of suboptimal cardiovascular risk profile. Results: The weighted prevalence of women aged

West Nile Virus (WNV) belongs to the Flaviviridae family of viruses. It was first isolated and identified in 1937. Patients typically present with flu-like symptoms or are asymptomatic; however, neuroinvasive West Nile can lead to significant neurological impairment. Herein presented is a catastrophic case of WNV rhombencephalitis in a male patient newly diagnosed with AIDS. This report sheds light on the potential for severe neurological complications in co-infected patients and emphasizes the importance of early recognition.

Coronavirus disease 2019–related transplant hepatic pseudoaneurysms have not been reported but can be life-threatening. They can be either solitary or multiple and can grow rapidly within weeks. They should be classified as mycotic and treated on an emergent basis. Both stenting of the vessel and coil embolization can potentially be viable treatment options of coronavirus disease 2019–related pseudoaneurysms.

Pneumothorax is a medical condition characterized by air in the space between the visceral and parietal pleural surfaces, with spontaneous and traumatic classifications. Spontaneous pneumothorax is further divided into primary and secondary groups based on the presence or absence of clinically apparent underlying lung disease. Here we present a case of a 23-year-old female with no past medical history who presented with chest pain and shortness of breath, ultimately diagnosed with primary spontaneous interlobar pneumothorax. Despite advancements in medical diagnosis techniques, spontaneous interlobar pneumothorax remains a rare presentation of pneumothoraces. Treatment strategies for clinically stable patients with a first episode of primary spontaneous pneumothorax include observation with or without supplemental oxygen, with further intervention only if the pneumothorax fails to improve or worsens.

Background: Postoperative shoulder stiffness (POSS) affects a large number of patients undergoing rotator cuff repair (RCR). Diabetes may increase the risk of POSS. Preoperative glycated hemoglobin (HbA1c) is a convenient measure of glucose control in this group. The aim of the present study was to determine a relationship between preoperative HbA1c and POSS in patients undergoing postero-superior RCR. Methods: Two hundred fifty patients with full-thickness postero-superior rotator cuffs who underwent RCR were followed for 6 months. Pre- and post-operative external rotation with arm by the side at 3 and 6 months were measured. Patient demographics, tear characteristics, preoperative HbA1c level, and surgical details were recorded. Patients with subscapularis tears, concomitant instability, partial thickness tears, arthritis, and irreparable rotator cuff tears were excluded. Univariate and multivariate logistic regression were used to determine the association between patient characteristics and POSS at 6 months. Results: At the end of 6 months, 16% (41/250) of patients had POSS. Multivariate analysis demonstrated an elevated preoperative HbA1c level was a statistically significant predictor of POSS at 6 months (odds ratio 7.04, P

The manuscript describes a case of Cavernous Malformation in the optic pathway which is extremely rare, accounting for less than 1% of central nervous system cavernomas. This case report highlights a patient initially diagnosed with a glioma, but subsequent MRI changes and extensive analysis ruled in favor of a hemorrhagic optic neuropathy caused by an optic nerve cavernoma. The patient experienced temporary vision loss but fully regained her vision within a week. Based on clinical, biochemical, and radiological findings, it was confirmed as a rare case of optic nerve cavernoma, and the patient was managed expectantly due to her complete recovery of vision. Follow-up imaging after 1 year indicated a stable lesion with evolving characteristics consistent with a cavernoma. This study provides an informative review of the condition and highlights the key radiologic features of this disease.

Acute disseminated encephalomyelitis (ADEM) is a rare immune-mediated demyelinating disorder primarily observed in children, typically triggered by recent vaccination or viral infection. Although uncommon, there have been reports of ADEM occurring in adults, with varying radiological findings compared to pediatric cases. Distinguishing ADEM from other demyelinating disorders, such as multiple sclerosis (MS) and neuromyelitis optica (NMO), can pose a diagnostic challenge. We present a case report of an 18-year-old male with a history of polysubstance use who was successfully treated with corticosteroids and highlight the neuroradiological presentation of ADEM, emphasizing the importance of accurate diagnosis and management in both pediatric and adult populations.

Cardiac disease associated with cancer treatment is a common adverse effect that is well-treated with appropriate monitoring. However, some cardiac adverse effects with cancer treatment are not well-understood, in particular rituximab-associated ventricular tachycardia. We present the fourth case of rituximab-associated ventricular tachycardia in a patient who is rituximab-naive and who does not have known cardiac disease history. This patient developed non-sustained polymorphic ventricular tachycardia 14 hours after rituximab was started and 6 hours after it was stopped, and after extensive monitoring including a 30-day event monitor, did not develop further significant runs of ventricular tachycardia.

Background:. Targeted muscle reinnervation (TMR), a surgical technique developed by the senior authors that coapts proximal ends of nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study is to describe the surgical technique for TMR of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) in nonamputee patients and provide data on postoperative functional outcomes. Methods:. A single-institution retrospective chart review was performed between March 2018 and April 2021. Patients were de-identified and included if they were nonamputees receiving TMR for pain in the peroneal nerve distribution. Data extracted included demographic information, symptoms before operation, relevant nerve coaptation, peri-, and postoperative complications, and long-term functional outcomes. Results:. Of the 19 patients reviewed, 11 patients underwent TMR of the SPN alone: eight had complete resolution of their symptoms; two indicated partial improvement in pain; and one patient had no improvement. Four patients underwent TMR of the DPN alone: two patients had complete resolution of their pain, and two patients had partial improvement with pain. Four patients underwent TMR of both the SPN/DPN: two patients had complete resolution of their symptoms, and two patients were noted to have significant improvement but had persistent pain from prior foot operations. Average follow-up time was 260 days. Conclusions:. TMR is a successful technique in the management of SPN and DPN neuroma pain. Our technique revealed excellent clinical outcomes, no procedure-specific complications, and improved subjective pain reports.

Citrobacter koseri (formerly classified as Citrobacter diversus ) is a gram-negative bacillus (GNB) that occurs as an opportunistic pathogen in neonates and immunocompromised patients. Citrobacter species have been implicated in nosocomial settings leading to infections involving the urinary tract, respiratory tract, liver, biliary tract, meninges, and even in rarer conditions—blood stream infection and infective endocarditis (IE). Gram-negative bacilli are responsible for 3% to 4% of all IE cases and have been traditionally associated with intravenous drug users. Patients with non-HACEK (species other than Haemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kinglella species) GNB IE have poor clinical outcomes with higher rates of in-hospital mortality and complications. The American Heart Association (AHA) and Infectious Diseases Society of America (IDSA) both recommend the use of combination antibiotic therapy with a beta-lactam (penicillins, cephalosporins, or carbapenems) and either an aminoglycoside or fluoroquinolones for 6 weeks (about 1 and a half months) to treat IE due to non-HACEK GNB. Citrobacter koseri is becoming more recognized due to its inherent resistance to ampicillin and emerging drug resistance to beta lactams and aminoglycosides requiring carbapenem therapy. Our case is of a 75-year-old male with no previously reported history of primary or secondary immunodeficiency disorders who developed C koseri blood stream infection. His infectious work-up revealed mitral valve IE and septic cerebral emboli resulting in ischemic infarcts. This case illustrates the importance of recognizing GNB organisms as rising human pathogens in IE cases even without active injection drug use or nosocomial exposure.

Although most patients with cardiac amyloidosis are diagnosed with either light chain (AL) or transthyretin (ATTR) disease, coexisting amyloid subtypes can occur. We present three cases of coexisting AL and ATTR cardiac amyloidosis and demonstrate the importance of clinical history and endomyocardial biopsy in diagnosis of this rare entity.

We present a case of 70-year-old male who had a very difficult to treat pancreatico-cutaneous fistula following surgery which we treated with combination of silver nitrate, betadine iodine and glue. Silver nitrate and betadine acted in combination to prevent infection while also causing sclerosis of the cavity and the fistula along with the glue.

We present a unique case of neurosarcoidosis diagnosed based on thyroid biopsy and FDG PET (Fluorodeoxyglucose positron emission tomography) imaging. A patient presented for a second opinion after being placed in hospice for rapidly progressing dementia, presumed to be due to Creutzfeldt Jakob disease despite negative workup and was unable to perform activities of daily life or communicate with his wife. The patient underwent a workup including whole-body FDG PET, which showed hypermetabolic lymph nodes as well as a hypermetabolic nodule in the thyroid. Biopsy of the lymph nodes was nondiagnostic, but the thyroid biopsy tissue yielded a diagnosis of sarcoid. After ruling out other causes and reviewing the tissue pathology, the patient was diagnosed with systemic sarcoidosis with neurological involvement and started on infliximab with rapid improvement.

Tobacco use remains the leading cause of preventable diseases and mortality in the United States. State quitline is an evidence-based tobacco cessation intervention for people who smoke. However, patients’ referral to quitline has been low. To address this gap in practice, we collected stakeholder feedback and engaged in an interdisciplinary and collaborative effort to create a new nicotine dependence treatment referral system using our electronic health record-based order sets. The project was conducted in 3 phases: (1) development process, (2) dissemination and approval from practice leaders, and (3) dissemination to clinicians. With the stakeholder feedback, we updated the existing nicotine dependence order set (NDO) by including links to the state quitline and local community resources targeting the social determinants of health. We created a brief educational material on the new NDO for dissemination. We measured the intention to use, implementation outcomes, acceptance, appropriateness, and feasibility of the new NDO. In the prepresentation survey, although 81% of the participants from the leadership and 77% from the clinician groups reported using the order set in general, only 13% from the leadership and 10% from the clinician group used the existing NDO. In the postpresentation survey, nearly 100% of the leadership and clinician respondents intended to use the new NDO in their practices. Acceptance (leadership vs clinicians: 82% vs 100%), appropriateness (leadership vs clinicians: 82% vs 95%), and feasibility (leadership vs clinicians: 82% vs 100%) were high in the postpresentation survey. Despite the positive reception to the new NDO, future research is needed to test the adoption, sustainability, and effectiveness of the NDO in addressing smoking cessation outcomes.

We report a case of portosystemic encephalopathy treated by retrograde transvenous obliteration (RTO) with an antecubital vein approach using a steerable triaxial system. A 77-year-old female was referred to our department complaining of dizziness and tremor. Laboratory data showed hyperammonemia. Contrast-enhanced CT and 3D-CT reconstruction images demonstrated an inferior mesenteric vein (IMV)-left common iliac vein shunt and a splenorenal shunt. The former was treated as a responsible shunt. The spleen volume was 212 mL, and the liver volume was 757 mL; giving a spleen/liver volume ratio of 0.3. Partial splenic artery embolization (PSE) was employed to control portal venous pressure. The hepatic venous pressure gradient (HVPG) changed from 13.2 to 9.6 mm Hg and the spleen/liver volume ratio improved from 0.3 to 0.2 by PSE. Two months after PSE, RTO with an antecubital vein approach using a steerable triaxial system was performed. HVPG changed to 12.5 mm Hg after RTO. Contrast-enhanced CT and 3D-CT reconstruction images 3 days after the procedure demonstrated the thrombus in the IMV-left common iliac vein shunt. We conclude that the antecubital vein approach using a steerable triaxial system is a feasible and minimally invasive technique in RTO for portosystemic shunts.

Male breast cancer is rare, with a lifetime risk of 1 in 833 males, with bilateral male breast cancer being extremely uncommon. This report describes a rare case of bilateral breast cancer in a 74-year-old male who presented with a breast lump and incidental calcifications in the contralateral breast. This case highlights the similarities, as well as differences, in presentation and imaging features of breast cancer in males and females. It also demonstrates how Magnetic Resonance Imaging can be a useful tool for pre-treatment planning of certain male breast cancers, especially to evaluate disease extent and to identify contralateral tumor.

Dysphagia is a common issue observed among the elderly, which can arise from various etiologies such as motility disorders and chronic neurologic conditions. Radiologists play a crucial role in diagnosing the cause of dysphagia, as they can identify anatomical abnormalities that may lead to the condition. One such anomaly is the hemiazygos vein, which is the left side equivalent of the azygos vein and can cause dysphagia if it crosses over the esophagus. To our knowledge, there are only 2 other recorded cases of azygos aneurysm/dilation causing esophageal dysphagia. In this context, we present a case report of a 73-year-old female with a 1-month history of weight loss and dysphagia due to a prominent hemiazygos vein. The case highlights the importance of thorough radiological evaluation in identifying the underlying cause of dysphagia and ensuring timely and appropriate treatment.

المخلص: أهداف البحث: حساسية باروريفلكس هي تقدير للتحكم اللاإرادي في الجهاز القلبي الوعائي عبر قوس منعكس الضغط. لقد تم اقتراح أن منعكس ضغط التمرين وعضلة ميتابوريفلكس يتجاوزان منعكس الضغط أثناء التمرين لتقليل اكتساب منعكس الضغط ، مما يسهل الارتفاع المتزامن في ضغط الدم ومعدل ضربات القلب أثناء التمرين. بحثت هذه الدراسة في تأثير تمرين قبضة اليد متساوي القياس على اكتساب منعكس الضغط والاعتماد على التردد لحساسية منعكس الضغط أثناء حدوث تقلبات في ضغط الدم الشرياني. طرق البحث: أجرى ثلاثة عشر رجلا بصحة جيدة تمارين قبضة اليد متساوية القياس بنسبة 20٪ و 30٪ من أقصى تقلص طوعي بينما تم تطبيق الضغط السلبي السفلي المتذبذب لأسفل الجسم البالغ 40 مم زئبق بترددات 0.1 و 0.25 هرتز. النتائج: مقارنة بالضغط السلبي التذبذب لأسفل الجسم عند تردد 0.25 هرتز لوحده ، تم تقليل مكاسب منعكس الضغط لضغط الدم الانبساطي بشكل كبير مع إضافة تمرين قبضة اليد متساوي القياس بنسبة 20٪ و 30٪ من الانكماش الطوعي الأقصى في نطاق التردد العالي. في حالة الراحة (بدون تمرين قبضة اليد متساوي القياس والضغط السلبي المتذبذب للجزء السفلي من الجسم) كان كسب منعكس الضغط أكثر بشكل ملحوظ في نطاق التردد العالي لضغط الدم الانبساطي. لكن اكتساب منعكس الضغط لضغط الدم الانبساطي لم يكن مختلفًا بشكل كبير عندما تم تطبيق تمرين قبضة اليد متساوي القياس + ضغط سلبي متذبذب لأسفل الجسم عند 20٪ و 30٪ من الانكماش الطوعي الأقصى في كلا الترددين. الاستنتاجات: قد يشير الانخفاض الملحوظ في كسب ضغط الدم الانبساطي مع إضافة تمرين قبضة اليد المتدرجة إلى أن انعكاس ضغط التمرين وعضلة ميتابوريفلكس تتجاوز انعكاس الضغط أثناء التمرين لتقليل اكتساب انعكاس الضغط في نطاق التردد العالي (0.25 هرتز). تم تغيير الظاهرة المعتمدة على التردد لحساسية الضغط المنعكس عندما تم تطبيق تمرين قبضة اليد متساوي القياس والضغط السلبي المتذبذب لأسفل الجسم ، وهذا يعني أن الاعتماد على التردد لحساسية منعكس الضغط قد تم إبطاله أثناء تمرين قبضة اليد متساوي القياس. Abstract: Objectives: Baroreflex sensitivity (BRS) is an estimate of autonomic control of cardiovascular system via the baroreflex arc. It has been suggested that exercise pressure reflex and muscle metaboreflex override baroreflex during exercise to decrease baroreflex gain, which facilitates the simultaneous rise in blood pressure (BP) and heart rate during the exercise. This study investigated the effects of isometric handgrip exercise (IHE) on baroreflex gain and frequency dependence of baroreflex sensitivity while fluctuations in arterial BP were generated. Methods: Thirteen healthy men performed IHE at 20% and 30% of their maximum voluntary contraction (MVC), while oscillatory lower body negative pressure (OLBNP) of 40 mmHg was applied in 0.1 and 0.25 Hz frequencies. Results: Compared to the OLBNP at 0.25 Hz frequency alone, the baroreflex gain for diastolic BP (DBP) was significantly reduced with the addition of IHE at 20% and 30% of MVC in the high frequency band. At rest (without IHE and OLBNP) the baroreflex gain was significantly more in the high frequency band for DBP, but the baroreflex gain for DBP was not significantly different when IHE + OLBNP were applied at 20% and 30% of MVC in both frequencies. Conclusions: The significant reduction of DBP baroreflex gain with the addition of graded IHE might indicate that exercise pressure reflex and muscle metaboreflex override baroreflex during exercise to decrease baroreflex gain at a high frequency band (0.25 Hz). The frequency-dependent phenomenon of BRS was altered when IHE and OLBNP were applied, meaning that the frequency dependence of BRS was nullified during IHE.

Objective: To evaluate the characteristics of individuals receiving lung cancer screening (LCS) and identify those with potentially limited benefit owing to coexisting chronic illnesses and/or comorbidities. Patients and Methods: In this retrospective study in the United States, patients were selected from a large clinical database who received LCS from January 1, 2019, through December 31, 2019, with at least 1 year of continuous enrollment. We assessed for potentially limited benefit in LCS defined strictly as not meeting the traditional risk factor inclusion criteria (age 80 years, previous computed tomography scan within 11 months before an LCS examination, or a history of nonskin cancer) or liberally as having the potential exclusion criteria related to comorbid life-limiting conditions, such as cardiac and/or respiratory disease. Results: A total of 51,551 patients were analyzed. Overall, 8391 (16.3%) individuals experienced a potentially limited benefit from LCS. Among those who did not meet the strict traditional inclusion criteria, 317 (3.8%) were because of age, 2350 (28%) reported a history of nonskin malignancy, and 2211 (26.3%) underwent a previous computed tomography thorax within 11 months before an LCS examination. Of those with potentially limited benefit owing to comorbidity, 3680 (43.9%) were because of severe respiratory comorbidity (937 [25.5%] with any hospitalization for coronary obstructive pulmonary disease, interstitial lung disease, or respiratory failure; 131 [3.6%] with hospitalization for respiratory failure requiring mechanical ventilation; or 3197 [86.9%] with chronic obstructive disease/interstitial lung disease requiring outpatient oxygen) and 721 (8.59%) with cardiac comorbidity. Conclusion: Up to 1 of 6 low-dose computed tomography examinations may have limited benefit from LCS.

A case of high-risk giant esophagogastric varices was treated by blood supply route-targeted endoscopic injection sclerotherapy with multiple ligations (EISML). An endoscope was inserted in the left lower semi-lateral position under general anesthesia in the digital subtraction angiography room. The C-arm was rotated to obtain a frontal view for fluoroscopy. Before puncturing the esophageal varices, the balloon attached to the tip of the endoscope was inflated to block the variceal blood flow. At puncture, an intravascular injection was confirmed fluoroscopically, and a total of 18 m of 5% ethanolamine oleate with iopamidol was injected retrogradely at 5-minute intervals from the esophagogastric varices to the root of the left gastric vein, maintaining stagnation for 25 minutes. The variceal site of the injection was ligated immediately after the removal of the needle to prevent variceal bleeding. Multiple variceal ligations were added to stop the variceal blood flow. Contrast-enhanced CT 3 days after EISML showed the thrombus formation in esophagogastric varices and the left gastric vein. The blood supply route-targeted EISML can be a feasible procedure for giant esophagogastric varices.

Summary:. Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

In 2022, the Food and Drug Administration approved a second mitral transcatheter edge-to-edge repair device for the treatment of primary mitral regurgitation (PASCAL Precision Transcatheter Valve Repair System, Edwards Lifesciences, Irvine, CA). The PASCAL Precision system consists of a guide sheath, implant system, and accessories. The implant system consists of a steerable catheter, an implant catheter, and the implant (PASCAL or PASCAL Ace). The guide sheath and steerable catheter move and flex independently from each other and are not keyed, allowing for freedom of rotation in three dimensions. This manuscript provides an overview of the PASCAL Precision system and describes the basic and advanced steering maneuvers to facilitate effective and safe mitral transcatheter edge-to-edge repair.

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: The debate between primary arthrodesis and open reduction and internal fixation(ORIF) of LisFranc injuries continues. Most of the available literature focuses on radiographic and clinical outcomes and fails to add the patient perspective to the analysis. A small number of high-quality studies have suggested superiority of arthrodesis over ORIF in certain patient populations but, thus far, age has not been analyzed as an independent variable. Some studies mention an aversion to performing arthrodesis in young patients but no evidence is available to support this claim. In this study, we analyze the effects of age on patient reported, clinical, and radiographic outcomes in LisFranc injuries. Methods: In this IRB approved study, a retrospective analysis of prospectively collected data was conducted on 108 patients with a mean age of 44.6 +/- 16 years who underwent either arthrodesis or ORIF for a LisFranc injury. All patients who underwent surgery between January 2016 and January 2022 were included in the analysis. Patients were excluded if they were younger than 18, did not meet the minimum follow-up duration of 3 months, and did not have both preoperative and postoperative patient reported outcome scores. Two age categories were created based on the median age of the cohort (18-40 years old and then 40- 81 years old) and analysis was performed based these age categories. Adaptive PROMIS Depression, Physical Function, and Pain interference scores were collected. Clinical and radiographic analysis was performed using the electronic medical record and PACs system. All statistical analysis was performed by someone with an expertise in statistics. Results: 163 patients who underwent either procedure during the time period were identified but 55 patients were excluded due to incomplete data or being underage. 61 patients (average age 44.7 +/-13) underwent ORIF and 47 patients (46.1 +/-16) underwent arthrodesis for LisFranc injuries. Within the ORIF cohort 25 (41%) were 18-40 years old and within the arthrodesis cohort 19 (40%) we 18-40 years old. No differences were observed between the two groups with regard to quality of reduction, complications, or PROMIS data. Anatomic or acceptable reduction was achieved in 92% of the ORIF cohort and 96% of the arthrodesis cohort. There was an increased rate of hardware removal in the ORIF group. See the attached table for complete results. Conclusion: In this study, age was not a predictor of outcomes after Lisfranc surgery whether performing an ORIF or an arthrodesis. Outcomes, both clinical and patient reported, for young patients in this cohort did not differ statistically regardless of whether the patient underwent ORIF or arthrodesis. The results of this study suggest that younger age should not deter a surgeon from arthrodesis if this is the procedure felt to be most appropriate in a given injury. Anatomic reduction led to consistently good patient reported outcomes regardless of surgical technique used.

Category: Other Introduction/Purpose: A basic requirement during a history and physical examination, in a foot and ankle clinic, is the ability to pinpoint where a patient experiences discomfort. Infrequently, patients are unable to localize their pain and “paint” over a non- anatomic distribution or point to multiple, independent areas across the foot. The ability to diagnose and treat a problem become significantly more difficult in these circumstances. In this study, the treatment course, clinical and patient reported outcomes(PROs) of patients who can pinpoint where they feel pain and those that “paint” over a non-anatomic area are compared. We hypothesize that patients unable to pinpoint are more likely to require advanced imaging studies, additional diagnostic modalities, and also less likely to improve in PROs at conclusion of treatment. Methods: Patients who presented in a foot and ankle clinic with foot pain between August 2021 and August 2022 were prospectively enrolled in this IRB approved study. The senior author completed a questionnaire after consultation identifying the patient as “able to pinpoint location of pain” or “unable to pinpoint location of pain.” Patients were excluded if they were < 18 years old, had neuropathy, or had pain as a result of a trauma (where does a trimalleolar ankle fracture hurt for example?). In cases where patients couldn’t pinpoint, they were counseled on localizing their symptoms and seen again 6 weeks later and given another chance to pinpoint. Diabetic patients had monofilament exams during presentation to control for undiagnosed neuropathy. Patients were followed for clinical outcomes, need for advanced imaging, need for additional diagnostic testing and finally PROs. All statistical analysis was conducted using GraphPad Prism(Ver 9.0, GraphPad Software, San Diego CA USA). Results: Overall, 423 patients were included (342 patients pinpointed and 91 patients did not). Patients unable to pinpoint were more likely to smoke (odds ratio=1.46) and to be diabetic (odds ratio=3.0). Patients with rheumatoid arthritis were more likely to be able to pinpoint(odds ratio=0.82) Patients unable to pinpoint presented with lower initial PROMIS Physical Function (40.0 vs. 43.3, p< 0.01) and increased Pain Interference (56.3 vs. 53.3, p< 0.01) and Depression (50.4 vs. 43.3, p< 0.01) then those that could localize. These patients were more likely to require advanced imaging (p=0.039) and diagnostic testing(EMG/image-guided injection) (p=0.044). Patient reported outcomes, in addition to starting out worse at presentation, did not see the same improvements at the conclusion of treatment. See the table for a summary of the key study findings. Conclusion: The ability to localize pain during a history and physical examination has direct bearing on a patients’ treatment course and outcomes in this single center study. Patients unable to pinpoint a location have lower initial and final PROs and also require more advanced imaging and diagnostic testing. Practitioners should continue to strive to better elucidate patient symptoms in hopes of more efficiently treating these patients. However, further research is needed to truly identify whether this presenting characteristic is truly indicative of patient outcomes.

ABSTRACT: Background: The diagnosis of spinal tuberculosis often relies on clinical, radiological, and laboratory findings, particularly in resource-constrained settings. However, numerous noninfectious conditions exhibit similar clinical and radiological features to spinal tuberculosis, leading to potential misdiagnosis in the absence of microbiological or histopathological confirmation. This study aims to present a case series from a developing country, highlighting noninfectious conditions that mimic spinal tuberculosis. Methods: A retrospective analysis was conducted on hospital records and imaging of patients diagnosed with spinal tuberculosis, lacking microbiological or histopathological evidence, and unresponsive to empirical antitubercular treatment. Patients displaying noninfectious conditions resembling spinal tuberculosis upon further investigation were included. Clinical and radiological findings of these patients were thoroughly analyzed. Results: Among a total of 23 patients observed over a 6-year period (2015–2020), various noninfectious conditions were identified as mimickers of spinal tuberculosis. These conditions included vertebral body haemangioma, ankylosing spondylitis (with or without Andersson lesion), rheumatoid pannus, osteoid osteoma, cystic hygroma, multiple myeloma, vertebral metastasis, malignant small round-cell tumor, pancreatic pseudocyst, esophageal duplication cyst, Modic changes in degenerative disc disease, Paget's disease, and psoas hematoma. Conclusion: Noninfectious spinal conditions can masquerade as spinal tuberculosis, underscoring the importance of obtaining a definitive tissue diagnosis before initiating antitubercular treatment. Particular attention should be given to features such as central lesions and the absence of soft tissue involvement in suspected cases of spinal tuberculosis, warranting a careful reconsideration of the diagnosis.

Objective: To examine outcomes in organ transplant and nontransplant patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the initial 22 months of the pandemic. Patients and Methods: We used Optum electronic health records to compare outcomes between an adult transplant group and a propensity-matched nontransplant group that tested positive for SARS-CoV-2 from February 1, 2020, to December 15, 2021. Baseline characteristics, hospitalization, intensive care unit admission, mechanical ventilation, renal replacement therapy, inpatient, and 90-day mortality were compared between the transplant and nontransplant groups and among specific transplant recipients. Cox proportional analysis was used to examine hospitalization and mortality by organ transplant, medical therapy, sex, and the period of the pandemic. Results: We identified 876,959 patients with SARS-CoV-2 infection, of whom 3548 were organ transplant recipients. The transplant recipients had a higher risk of hospitalization (30.6% vs 25%, respectively; P

We report a case of life-threatening bleeding from gastric varices in a patient with alcoholic cirrhosis, which was treated by emergency transileocolic vein obliteration (TIO). A 46-year-old male with a massive hematemesis was transported to our hospital by ambulance. Contrast-enhanced computed tomography demonstrated large gastric varices. Temporary hemostasis using balloon tamponade was attempted, however, bleeding could not be controlled, and his vital signs were unstable despite massive blood transfusions. First, endoscopic treatment was attempted, but the visual field could not be secured due to massive bleeding. Therefore, emergency TIO under general anesthesia was attempted. After laparotomy, 5 Fr. sheath was inserted into the ileocolic vein. Posterior and left gastric veins, which were the blood supply routes of gastric varices, were identified and embolized using microcoils and a 50% glucose solution. Hemostasis was achieved and vital signs recovered. Three days after TIO, transjugular retrograde obliteration was attempted successfully to embolize the residual gastric varices. After the procedures, his condition improved. We conclude that emergency TIO is a useful rescue option for life-threatening bleeding from gastric varices if endoscopic treatment or balloon tamponade is ineffective.