Laparoscopic Sleeve Gastrectomy in Monozygotic Twins: Report of the First Case

Obesity is an epidemic disease that is believed to link to other pathologies as well as life-threatening cardiovascular pathology. Here we report a case of monozygotic twins who successfully lost weight following laparoscopic sleeve gastrectomy at the end of the 18-month follow-up period. We aimed to determine the factors affecting the weight loss outcome after sleeve gastrectomy in monozygotic twins. The twins' initial BMIs were 37.1 kg/m2 and 40.2 kg/m2, respectively. Twin A's excess weight loss was 48.4%, 61.3%, 80.6%, 96.8%, and 112.9% at three, six, nine, 12 and 18 months, while Twin B's in the third, sixth, ninth, 12th and 18th months was 23.1%, 41%, 51.3%, 61.5% and 71.8%. On the third, sixth, ninth, 12th, and 18th months of Twin A, the total weight loss was 15.8%, 20%, 26.3%, 31.6%, and 36.8%. In Twin B in the third, sixth, ninth, 12th, and 18th months, it was 8.7%, 15.5%, 19.4%, 23.3%, and 27.2%. When the twins were compared in terms of excess weight loss and total weight loss at 18 months, Twin A was more successful than Twin B. Especially at this point, Twin B's having a child (three years old) at a young age, her low compliance with the recommendations in the post-operative period and her difficulty in changing her lifestyle, environmental factors are as important as hereditary factors in achieving weight loss and a healthy body mass index (BMI) range.

Closed system paravertebral abscess evacuation on spinal infection: A case series

INTRODUCTION

Paravertebral abscess is a common complication of spondylitis tuberculosis which has high prevalence in Indonesia. Surgical intervention such as open surgery or endoscopic debridement is needed to remove and drainage the abscess in addition to chemotherapy. However, this surgeries have several complications such as soft tissue damage and abscess contamination to the healthy tissue. We reported closed system strategy to evacuate the paravertebral abscess on spinal infection.

METHODS

The technique is performed by orthopaedic team under guidance of the C-Arm and ultrasound sonography (USG) in March-June 202. The needle which connected to 20 cc syringe is inserted into the lesion to aspirate the abscess. After evacuation of the abscess, 2-g broad spectrum antibiotic is injected through the needle to eradicate the bacteria locally.

RESULTS

We performed the closed system paravertebral abscess evacuation in three patients, a 30-year-old male, 43-year-old male, and 22-year-old female. All the patients had back pain and limitation spine movement due to pain and were diagnosed with spondylitis and paravertebral abscess based on the plain radiography and magnetic resonance imaging (MRI). It reported that up to 2000 cc abscess can be evacuated with this micro invasive technique.

CONCLUSION

The closed system is a micro-invasive procedure result in minimal soft tissue injury and faster recovery. It succesfully remove paravertebral abscess followed by direct antibiotic eradication on spinal infection.

Posterior Petrous Meningiomas: Surgical Classification and Postoperative Outcomes in a Case Series of 130 Patients Operated via the Retrosigmoid Approach

OBJECTIVE

A standardized definition and classification of primary posterior petrous meningiomas (PPMs) is lacking, with consequent challenges in comparing different case series. This study aimed to provide an anatomical description and classification of PPMs analyzing a homogeneous series of patients operated via the retrosigmoid approach.

METHODS

PPMs originate laterally to the petro-occipital fissure within the venous ring composed of the superior petrosal, sigmoid, inferior petrosal, and cavernous sinuses. We proposed a classification based on tumor site of origin, direction of growth relative to the internal acoustic meatus, and cranial nerves' displacement. Four types of PPMs were defined: retromeatal (type A), meatal (type B), premeatal (type C), and broad-based (type D). We performed a retrospective analysis of 130 consecutive patients with PPMs who underwent surgery as first-line treatment.

RESULTS

The PPM classification predicted clinical presentation, postoperative morbidity, and resection rates. Headache, hydrocephalus, and cerebellar deficits were more common in type A (59.0%, 37.7%, 49.2%) and type D (66.7%, 66.7%, 33.3%). Hypoacusia/anacusia was more common in type B (87.5%), while trigeminal hypoesthesia/anesthesia was more common in type C (85.0%). After surgery, patients with type A and D PPMs were at higher risk to develop cerebellar deficits (11.5%-22.2%), whereas patients with type B and C PPMs presented with hypoacusia/anacusia (12.5%) and trigeminal deficits (10.0%), respectively. The near-total resection rate was higher in type A (91.8%), followed by types B (82.5%), C (80.0%), and D (77.8%) PPMs.

CONCLUSIONS

The PPM surgical classification has an operative and prognostic relevance. In expert hands, the retrosigmoid approach represents a safe and effective approach to remove PPMs.

Spinal Intradural Arachnoid Cysts in Adults: An Institutional Experience and Literature Review

BACKGROUND

Adult spinal intradural arachnoid cysts are rare pathologic entities with an unclear etiopathogenesis. These lesions can be dichotomized into primary (idiopathic) or secondary (related to inflammation, intradural surgery, or trauma) etiologies. Limited series have depicted optimal management strategies and clinical outcomes.

OBJECTIVE

To illustrate our experience with spinal intradural arachnoid cysts and to present a literature review of surgically treated cysts to elucidate the clinical and anatomic differences between etiologies.

METHODS

Institutional review revealed 29 patients. Various data were extracted from the medical record. Initial and follow-up symptomatologies of the surgical cohort were compared. The literature review included case series describing cysts managed surgically.

RESULTS

From patients treated surgically at our institution (22), there was a significant reduction in thoracic back pain postoperatively ( P = .034). A literature review yielded 271 additional cases. Overall, primary and secondary lesions accounted for 254 and 39 cases, respectively. Cysts of secondary origin were more likely localized ventral to the spinal cord ( P = .013). The rate of symptomatic improvement after surgical intervention for primary cysts was more than double than that of secondary cysts ( P < .001). Compared with primary etiologies, the rates of radiographic progression ( P = .032) and repeat surgery ( P = .041) were each more than double for secondary cysts.

CONCLUSION

Surgical intervention for spinal intradural arachnoid cysts improves thoracic back pain. The literature supports surgical intervention for symptomatic primary spinal intradural arachnoid cysts with improved clinical outcomes. Surgery should be cautiously considered for secondary cysts given worse outcomes.

Complications Related to Deep Brain Stimulation Lead Implantation: A Single-Surgeon Case Series

BACKGROUND

Deep brain stimulation (DBS) is the mainstay of surgical treatment for movement disorders, yet previous studies have shown widely varying complication rates. Given the elective nature of DBS surgery, minimizing surgical complications is imperative.

OBJECTIVE

To evaluate short-term and long-term complications related to DBS lead implantation surgeries performed by an experienced surgeon and provide an updated benchmark comparison for other DBS centers and alternative therapies.

METHODS

A retrospective chart review of patients who underwent DBS lead implantation surgery by a single surgeon at our institution between 2012 and 2020 was conducted. Demographic and clinical data including surgical complications were collected. A Kaplan-Meier survival analysis was used to evaluate the cumulative risk of lead revision or removal over time. Associations between patient characteristics and various complications were evaluated.

RESULTS

Four hundred fifty-one DBS leads were placed in 255 patients. Thirteen leads and 11 patients required revision. In total, 3.6% (95% CI [1.3%-5.9%]) of patients required revision at 1 year and 4.8% (95% CI [1.9%-7.6%]) at 5 years, with per-lead revision rates of 2.3% (95% CI [0.9%-3.6%]) and 3.3% (95% CI [1.5%-5.1%]), respectively. Less common diagnoses such as Tourette syndrome, post-traumatic tremor, and cluster headache trended toward association with lead revision or removal.

CONCLUSION

DBS performed by an experienced surgeon is associated with extremely low complication rates.

Intrathecal Baclofen and Opioid Therapy: Cerebrospinal Fluid Leak and Infection Incidence, Risk Factors, and Outcomes

BACKGROUND

Intrathecal drug therapy treats medically refractory spasticity and pain. cerebrospinal fluid (CSF) leak or infection can limit efficacy and increase morbidity. We aim to evaluate risk factors and outcomes after CSF leaks and infections requiring reoperation.

MATERIALS AND METHODS

We retrospectively analyzed our 7-year experience of intrathecal baclofen and opioid operations using a protocol designed to limit CSF leakage and infections. Postoperative complication incidence and risk factors for reoperation were compared with published reports. We assessed outcomes after these complications.

RESULTS

We analyzed 282 intrathecal baclofen (ITB) and intrathecal opioid (ITO) therapy operations (mean 2.27-year follow-up). 21% developed CSF leaks overall with similar incidences in ITB and ITO patients (19% vs. 25%, p0.3). Overall, 5% of patients developed deep infections with similar incidences between ITB and ITO cohorts (6% vs. 4%, p0.6). Tobacco use and age <50 years were significantly associated with CSF leak in ITO operations. Underweight body mass index, immunosuppression, tobacco use, and primary implantation were associated with infection. When CSF leak or infection occurred, patients suffered more perioperative adverse events and had elevated 90-day readmission rate compared with those without these complications.

CONCLUSIONS

Our 7-year ITB and ITO therapy using the 8781 Ascenda intrathecal catheter highlights a higher reoperation rate for CSF leak and similar infection incidence to reports using traditional catheters. Multiple modifiable risk factors for CSF leak include recent tobacco use among ITO patients. Body mass index optimization and immunosuppressant elimination may reduce reoperation for infection.

The value of case reports in diagnostic radiography

OBJECTIVE

- This paper sought to explore the value of case reports in diagnostic radiography with regards to current usage, relevance to evidence-based radiography, and educational benefits.

KEY FINDINGS

Case reports are short accounts of novel pathologies, trauma or treatment with a critical review of relevant literature. Examples within diagnostic radiography include the appearances of COVID-19 alongside examination-level scenarios involving image artefacts, equipment failure and patient incidents in radiology. With greatest risk of bias and lowest generalisability, they are considered as low-quality evidence with generally poor citation rates. Despite this, there are examples of significant discoveries or developments initiated with case reports with important patient care implications. Furthermore, they offer educational development for both reader and author alike. Whereas the former learns about an unusual clinical scenario, the latter develops scholarly writing skills, reflective practice and may generate further, more complex, research. Radiography-specific case reports could capture the diverse imaging skills and technological expertise currently under-represented in traditional case reports. Potential avenues for cases are broad and may include any imaging modality where patient care or safety of other persons may illicit a teaching point. This encapsulates all stages of the imaging process, before, during and after patient interaction.

CONCLUSION

Despite being low-quality evidence, case reports contribute to evidence-based radiography, add to the knowledge base, and foster a research culture. However, this is contingent upon rigorous peer-review and adherence to ethical treatment of patient data.

IMPLICATIONS FOR PRACTICE

With the drive to increase research engagement and output at all levels in radiography (student to consultant), case reports may act as a realistic grass-root activity for a burdened workforce with limited time and resources.

Single bundle vs double bundle for anterior cruciate ligament reconstruction evaluated with T2 mapping: A case series

INTRODUCTION

ACL reconstruction is needed to restore the stability and biomechanics properties of the injured knee joints in order to reproduce the function of the native ACL. The single-bundle (SB) and double-bundle (DB) techniques are most commonly used to reconstruct the injured ACL. However, its superiority upon each other is still controversial.

PRESENTATION OF CASE

This study presented a case series of six patients underwent ACL reconstruction, consisted of three patients with SB ACL reconstruction and three patients with DB ACL reconstruction with further T2 mapping for joint instability evaluation. Only two DB patients showed consistent decreased value in every follow-up.

DISCUSSION

ACL tear can generate joint instability. Joint instability is resulted from two mechanisms of relative cartilage overloading. First, there is an abnormal load distribution due to shifting of the center of pressure of the tibiofemoral force, resulting in increased stresses on the articular cartilage of the knee joint. There is also an increase of translation between articular surfaces, resulting in increased shear stresses on the articular cartilage. A trauma of knee joint causes cartilage damage and increased oxidative and metabolic stress of chondrocytes, resulting in chondrocyte senescence acceleration.

CONCLUSION

This case series showed inconsistent results to determine either SB or DB has a better outcome in joint instability, thus further larger studies are needed.

Study design methodology in neurosurgical research

Background

Medical research has evolved from individual expert-described opinions and techniques to scientifically designed methodology-based studies. There are different study designs, and selecting an appropriate study design is critical to appropriately answer the research question being investigated.

Main body

A research question may be addressed using different approaches that can be descriptive, analytical, or experimental. The choice of study design is influenced by features as that related to exposure (intervention) and disease (outcome); considerations related to time, resources, ethics and gaps in scientific knowledge that remain to be filled. The purpose of this review is to provide an overview of the basic study designs as it is the foundation of neurosurgical research to provide valid scientific evidence.

Conclusion

Quality in scientific research begins with a clear hypothesis and a well-formulated design. This entails a thorough understanding of the different study designs to choose the best suited to answer the investigated research question.

Thyroglossal duct diseases: presentation and outcomes

OBJECTIVE

The incidence of thyroglossal duct diseases in the general population is about 7%. We aimed to demonstrate the clinical presentations and management of thyroglossal duct diseases.

METHODS

We conducted a retrospective review of all patients who underwent surgery for histopathologically confirmed thyroglossal duct cyst, sinus, or fistula at a single center.

RESULTS

A total of 151 cases were included in this study. There were more female patients (87, 58%) than male patients (64, 42%). The patients' ages ranged from 1 to 63 years old. The most prevalent complaint was painless upper midline neck swelling (93.3%). Most cases were diagnosed as thyroglossal duct cysts (137, 90.7%). Six cases (4%) were associated with carcinoma. All the cases were managed using the modified Sistrunk procedure. There were no procedure-related complications, and five cases of recurrence.

CONCLUSIONS

Although thyroglossal duct cyst is the most common neck anomaly in children, it may also present with various characteristics later in life. This condition can be managed successfully without complications and with a low recurrence rate.

Detection of immunoreactive proteins of Escherichia coli, Streptococcus uberis, and Streptococcus agalactiae isolated from cows with diagnosed mastitis

Introduction

Mastitis is a widespread mammary gland disease of dairy cows that causes severe economic losses to dairy farms. Mastitis can be caused by bacteria, fungi, and algae. The most common species isolated from infected milk are, among others, Streptococcus spp., and Escherichia coli. The aim of our study was protein detection based on both in silico and in vitro methods, which allowed the identification of immunoreactive proteins representative of the following species: Streptococcus uberis, Streptococcus agalactiae, and Escherichia coli.

Methods

The study group included 22 milk samples and 13 serum samples obtained from cows with diagnosed mastitis, whereas the control group constituted 12 milk samples and 12 serum samples isolated from healthy animals. Detection of immunoreactive proteins was done by immunoblotting, while amino acid sequences from investigated proteins were determined by MALDI-TOF. Then, bioinformatic analyses were performed on detected species specific proteins in order to investigate their immunoreactivity.

Results

As a result, we identified 13 proteins: 3 (molybdenum cofactor biosynthesis protein B, aldehyde reductase YahK, outer membrane protein A) for E. coli, 4 (elongation factor Tu, tRNA uridine 5-carboxymethylaminomethyl modification enzyme MnmG, GTPase Obg, glyceraldehyde-3-phosphate dehydrogenase) for S. uberis, and 6 (aspartate carbamoyltransferase, elongation factor Tu, 60 kDa chaperonin, elongation factor G, galactose-6-phosphate isomerase subunit LacA, adenosine deaminase) for S. agalactiae, which demonstrated immunoreactivity to antibodies present in serum from cows with diagnosed mastitis.

Discussion

Due to the confirmed immunoreactivity, specificity and localization in the bacterial cell, these proteins can be considered considered potential targets in innovative rapid immunodiagnostic assays for bovine mastitis, however due to the limited number of examined samples, further examination is needed.

Serratus plane block with sedation for patients submitted to axillary dissection: a prospective case series

Axillary dissection is a standard surgical procedure for stage III skin and soft tissue tumors and is usually performed under general anesthesia. This study aimed to investigate the feasibility of performing axillary dissection with Serratus muscle plane block plus intravenous sedation. Fifteen patients undergoing axillary dissection were prospectively recruited. The patients were evaluated during their pre-operative anesthetic appointment, during their procedure, and at post-operative days 1 and 30. The blockade was performed superficial to the Serratus muscle at the level of fourth rib. Sedation was performed using propofol, fentanyl, dexmedetomidine, and S-ketamine. None of the patients required conversion to general anesthesia. Surgeons showed a highly positive response when asked about the anesthetic technique, and most of them found the technique "indistinguishable" from general anesthesia. The median (interquartile range) pain scores at rest over all time frames was 0 (0-0). Furthermore, no patients developed nausea, hemodynamic instability, or any complications associated with the technique. The Serratus plane block associated with intravenous sedation proved feasible for axillary lymphadenectomy, however, further clinical trials should evaluate potential advantages compared to other techniques.

Аre Multivisceral Resections for Gastric Cancer Acceptable: Experience from a High Volume Center and Extended Literature Review?

Introduction  Multivisceral resections (MVRs) in gastric cancer are potentially curable in selected patients in whom clear resection margins are possible. However, there are still uncertain data on their feasibility and safety considering short- and long-term results. The study compares survival, morbidity, mortality, and other secondary outcomes between standard and MVRs for gastric cancer. Materials and Methods  A monocentric retrospective study in patients with gastric adenocarcinoma, covering 2004 to 2020. Of the 336 operable cases, 101 patients underwent MVRs. The remaining 235 underwent standard gastric resections (SGRs), of which 173 patients were in stage T3/T4. To compare survival, a control group of 101 patients with palliative procedures was used-bypass anastomosis or exploration. Results  MVR had a lower survival rate than the SGR but significantly higher than the palliative procedures. The predominant gender in MVR was male (72.3%), with a mean age of 61 years. The perioperative mortality was 3.96% ( n  = 4), and the overall median survival was 28.1 months. The most frequently resected organs were the spleen (67.3%), followed by the pancreas (32.7%) and the liver (20.8%). In 56.4% of the cases two organs were resected, in 28.7% three organs, and in 13.9% four organs. The main complication was bleeding (9.9%). The major postoperative complications in the MVR were 14.85%, and in the SGR 6.4% ( p  < 0.05). Better long-term results were observed in patients who underwent R0 resections compared with R1. Conclusion  Multiorgan resections are characterized by poorer survival and a higher complication rate than gastrectomies. On the other hand, they have better long-term outcomes than palliative procedures. However, MVRs are admissible when performed by an experienced surgical team in high-volume centers.

Simultaneous Anterior Posterior Approach for Single-Position Lateral Lumbar Interbody Fusion with Robotic Assistance: Technical Guidelines and Early Outcomes

BACKGROUND

Lumbar lateral interbody fusion (LLIF) is traditionally performed in 2 stages: placing the interbody cage in the lateral decubitus position, then placing the percutaneous pedicle screw in the prone position. Performing interbody fusion and posterior fixation simultaneously could improve operative efficiency and clinical outcomes associated with longer operative times. We describe the operative steps and report clinical and radiographic outcomes associated with a simultaneous anterior and posterior approach (SAPA) for LLIF.

METHODS

Patients who underwent SAPA LLIF performed by a single surgeon over 1 year were retrospectively reviewed. Demographic, clinical, and radiographic data were analyzed, an operative guideline was created, and a learning curve was constructed using operative times.

RESULTS

SAPA LLIF was performed in 11 patients. Three patients experienced transient postoperative femoral nerve plexopathy with symptoms of ipsilateral hip flexion weakness and/or anterior thigh numbness; there were no other complications in the cohort. Radiographically, patients achieved significant increases in disc height (8.3 mm vs. 13.5 mm, P = 0.002) and foraminal height (20.2 mm vs. 25.3 mm, P = 0.0001). Patients showed significant improvements in Oswestry Disability Index (52 vs. 27.8, P = 0.002) and Patient-Reported Outcome Measurement Information System Physical Function (32.6 vs. 39, P = 0.048) and Pain Interference (64.9 vs. 59.6, P = 0.001) at 3 months. A downward trend in operative time was observed for 1-level SAPA LLIF.

CONCLUSIONS

SAPA LLIF is a safe approach for LLIF that results in favorable clinical outcomes. This technique can potentially improve operative efficiency further along the course of a surgeon's learning curve.

Management of Traumatic Atlantooccipital Dissociation at a Level 1 Trauma Center: A Retrospective Case Series

OBJECTIVE

Atlantooccipital dislocation (AOD) is a highly unstable and often neurologically devastating injury to the craniocervical junction that typically results from high-energy trauma. Management of these devastating injuries is complex, with prognostication difficult due to high rates of concomitant intracranial and systemic injuries. This report highlights advances in management of AOD and appropriate implementation of operative adjuncts including neuronavigation and the use of intraoperative neuromonitoring.

METHODS

All patients with AOD presenting to a high-volume, level 1 trauma center between January 2015 and August 2021 were retrospectively identified through a prospectively maintained database of patients presenting with traumatic spine injuries. Medical records, including imaging reports, clinical documentation, and intraoperative neurophysiological reports were reviewed.

RESULTS

A total of 11 patients were identified with patterns of injury consistent with AOD. Fifty-five percent of patients survived until discharge. 73% of patients underwent surgery for stabilization. All 4 patients with preoperative neurologic deficits who underwent surgery had monitorable transcranial motor evoked potentials and somatosensory evoked potentials. Two experienced significant motor recovery postoperatively, and 2 did not survive to discharge. Blunt cerebrovascular injuries were identified in 73% of patients.

CONCLUSION

AOD is encountered with increasing frequency. The identification and management of this specific injury is complicated by the volume and severity of associated injuries, especially concomitant traumatic brain injury. Timely recognition is critical and the use of surgical adjuncts including intraoperative neurophysiologic monitoring and surgical navigation can increase the safety and success of these procedures while also providing prognostic information on potential for motor recovery.

Outcomes of Arterial Bypass for Posterior Circulation Atherosclerosis: A Case Series

BACKGROUND

Extracranial-intracranial bypass is an effective treatment option for moyamoya disease and in well-selected cases of anterior circulation intracranial atherosclerotic disease; however, the effectiveness of bypass is less evident in posterior circulation atherosclerosis. Updated surgical techniques and clinical guidelines necessitate modern appraisal of arterial bypass for symptomatic patients with posterior circulation atherosclerotic disease who are refractory to medical management.

OBJECTIVE

To evaluate the complications, graft patency, and postoperative outcomes of arterial bypass for posterior circulation intracranial atherosclerotic disease.

METHODS

Perioperative records of consecutive bypass patients were retrospectively evaluated to determine the clinical course and surgical outcomes.

RESULTS

Arterial bypass was performed in 8 cases with a median age of 62 years. All 8 patients underwent direct bypass with an autologous occipital artery donor vessel. Recipient vessel selection varied on a case-by-case basis, with the superior cerebellar artery used in 4 cases, the posterior inferior cerebellar artery in 3 cases, and the anterior inferior cerebellar artery in 1 case. There were no significant intraoperative or postoperative complications. Postoperatively, all 8 patients displayed clinical improvement of their preoperative symptoms, with a significant decrease of 2.5 points on the modified Rankin Scale (P < .001). Postoperative imaging confirmed full graft patency in 7 patients and partial patency in 1 patient.

CONCLUSION

Excellent postoperative outcomes and no major complications after posterior circulation arterial bypass for intracranial atherosclerotic disease highlight the utility of this intervention for the treatment of medically refractory or symptomatic posterior circulation intracranial atherosclerotic disease. Larger studies may be valuable to validate these findings.

Clinical features, natural history and outcomes of pseudolymphoma of liver: A case-series and systematic review

BACKGROUND

Pseudolymphoma is a rare, benign, nonspecific condition that forms a mass-like lesion characterized by the proliferation of non-neoplastic lymphocytes. Lacking of specific clinical symptoms, serological markers, and imaging features, the diagnosis is difficult. We reporte five cases of hepatic pseudolymphoma and provide a systematic review of existing literatures to improve our understanding of this rare liver disease.

METHODS

We followed-up five cases of hepatic pseudolymphoma in West China Hospital from January 2002 to January 2022. We also summarized the cases of hepatic pseudolymphoma from January 1981 to December 2021 through the PubMed database and comprehensively analyzed the characteristics of the cases.

RESULTS

The pathologic features of the five cases were characterized by benign lymphoid tissue hyperplasia, lymphoid follicle formation, and a polarized germinal center. Immunohistochemistry, in situ hybridization, and gene rearrangement revealed non-malignant lymphoma. Besides, a total of 116 cases have been reported in the PubMed database from 1981 to 2021. The incidence of hepatic pseudolymphoma is higher in middle-aged and elderly women and has been reported more frequently in Asia. All cases were pathologically diagnosed, among which 85.95% of the patients were treated by surgery.

CONCLUSIONS

Hepatic pseudolymphoma is an extremely rare benign disease, mainly in middle-aged and elderly women. Without distinctive clinical and imaging characteristics, pathological diagnosis is the highly reliable method at present. Thus, in the absence of risk factors for a primary liver tumor or metastatic tumor in middle-aged and elderly women, the possibility of pseudolymphoma should be considered to avoid extensive treatments.

Neuroinflammation and neovascularization in diabetic eye diseases (DEDs): identification of potential pharmacotherapeutic targets

The goal of this review is to increase public knowledge of the etiopathogenesis of diabetic eye diseases (DEDs), such as diabetic retinopathy (DR) and ocular angiosarcoma (ASO), and the likelihood of blindness among elderly widows. A widow's life in North India, in general, is fraught with peril because of the economic and social isolation it brings, as well as the increased risk of death from heart disease, hypertension, diabetes, depression, and dementia. Neovascularization, neuroinflammation, and edema in the ocular tissue are hallmarks of the ASO, a rare form of malignant tumor. When diabetes, hypertension, and aging all contribute to increased oxidative stress, the DR can proceed to ASO. Microglia in the retina of the optic nerve head are responsible for causing inflammation, discomfort, and neurodegeneration. Those that come into contact with them will get blind as a result of this. Advanced glycation end products (AGE), vascular endothelial growth factor (VEGF), protein kinase C (PKC), poly-ADP-ribose polymerase (PARP), metalloproteinase9 (MMP9), nuclear factor kappaB (NFkB), program death ligand1 (PDL-1), factor VIII (FVIII), and von Willebrand factor (VWF) are potent agents for ocular neovascularisation (ONV), neuroinflammation and edema in the ocular tissue. AGE/VEGF, DAG/PKC, PARP/NFkB, RAS/VEGF, PDL-1/PD-1, VWF/FVIII/VEGF, and RAS/VEGF are all linked to the pathophysiology of DEDs. The interaction between ONV and ASO is mostly determined by the VWF/FVIII/VEGF and PDL-1/PD-1 axis. This study focused on retinoprotective medications that can pass the blood-retinal barrier and cure DEDs, as well as the factors that influence the etiology of neovascularization and neuroinflammation in the eye.

Involving Older People With Frailty or Impairment in the Design Process of Digital Health Technologies to Enable Aging in Place: Scoping Review

BACKGROUND

With an increase in life expectancy globally, the focus on digital health technologies that can enhance physical and mental health among older people with frailty and impairment has increased. Similarly, research interest in how digital health technology can promote well-being and self-management of health in older age has increased, including an increased focus on methods for designing digital health technologies that meet the various medical, psychological, and social needs of older population. Despite the increased focus, there remains a necessity to further understand the needs of this population group to ensure uptake and to avoid introduction of additional challenges when introducing technologies, for example, because of poor technological design. The scope is limited to digital health technologies meant to enable older people with frailty and impairment to age in place.

OBJECTIVE

In this study, we aimed to explore how older people with frailty and impairment are involved in various parts of the design processes of digital health technologies and identify gaps or neglected steps in a user-involving design process. This included a focus on recruitment strategies, contributions, and methods used to address the perspectives, needs, and desires of older people with frailty and impairment in the development of digital health technologies.

METHODS

A scoping review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) reporting from February 2021 to April 2021. Literature searches were conducted in PubMed, Scopus, Embase, and IEEE using a search string covering the concepts of health technology, older people, frailty and impairment, user-centered design, and self-management.

RESULTS

In total, 1891 studies were imported for screening from the initial search. A total of 22 studies were included in this review after full-text screening and manual search. Invitation through partners was the most reported recruitment strategy to involve older people with frailty and impairment in the design process of digital health technologies. Furthermore, they were commonly involved in the final evaluation of the development process. Three main gaps identified were the use of outreach approaches to recruit older people with frailty and impairment in the design process of digital health technologies, description of the value of involvement and outcome of the contribution of participants, and knowledge regarding involvement in all parts of the design process.

CONCLUSIONS

Although there is literature on methods for involving older people with frailty and impairment in the design of digital health technology, there is little methodological dialogue on the nuances of how different methods for involvement relate to and shape the outcome of the development process.

Modified Lateral Orbitotomy Approach to Lesions of the Orbital Apex, Superior Orbital Fissure, Cavernous Sinus, and Middle Cranial Fossa

BACKGROUND

The lateral orbitotomy approach (LOA) provides minimally invasive access to the orbit, cavernous sinus region, and middle cranial fossa. Orbital retraction with this approach can nonetheless injure orbital structures, causing unnecessary morbidity.

OBJECTIVE

To describe our clinical experience with the modified LOA (mLOA), wherein the medial aspect of the lateral orbital wall posterior to the orbital rim is preserved.

METHODS

This is a retrospective, single-institution case series of patients undergoing a mLOA for lesions of the orbital apex, superior orbital fissure, cavernous sinus, and middle cranial fossa. The dimensions and variance of selected anatomic parameters relevant to this approach (orbital rim-superior orbital fossa depth, lateral orbital wall angle) were also analyzed using computed tomography scans from 30 adult patients.

RESULTS

Eight patients underwent a mLOA (mean age 54.0 ± 19.6 years; 3 males). Surgical targets included the superior orbital fissure (2; cavernoma and meningioma), sphenoid wing with or without the orbital apex (2; meningioma), cavernous sinus (2; rule out carcinoma and smooth muscle tumor), and anterior/mesial temporal lobe (2; cavernoma). Visual acuity/fields and diplopia was stable or improved in all patients postoperatively. One patient experienced a cerebrospinal fluid leak. On computed tomography analysis, the relevant bony anatomy displayed limited variability, with a mean orbital fossa depth of 42.7 ± 2.8 mm and a lateral orbital wall angle of 44.4° ± 2.7°.

CONCLUSION

The mLOA can provide safe, minimally invasive access to select lesions of the orbital apex, superior orbital fissure, cavernous sinus, and middle cranial fossa. The operative corridor has relatively consistent bony anatomy.

A systematic cohort review of pheochromocytoma-induced typical versus atypical Takotsubo cardiomyopathy

BACKGROUND

A rare presentation of pheochromocytoma (PCC) is catecholamine-induced-cardiomyopathy, or Takotsubo cardiomyopathy (TCM). PCC-induced TCM(PCC-TCM) can present as a typical or atypical type, based on the location of cardiac wall motion abnormalities. In this review, we sought to assess features and outcomes for PCC-TCM, and to compare typical and atypical subtypes.

METHODS

A search was conducted on two databases (PubMed and Embase) for case series or reports on PCC-TCM from 2006 to 2020.

RESULTS

One-hundred-and-two papers with a total of 104 cases of PCC-TCM were retrieved: 67(64.4%) typical and 37(35.6%) atypical subtypes. Overall median age was 50[range:23-86] years, the atypical group about a decade younger(p < 0.001). A female preponderance was seen for either subtype (∼75%). The most common presentations were chest pain(n = 60;58%), dyspnoea(n = 46;44%), and headache(n = 41;39.4%). Those with atypical subtype more often presented with fluid overload (typical:3% versus atypical:60%); acute pulmonary oedema (35% versus 60%); and cardiogenic shock (22% versus 43%) (all p < 0.05). Six patients (6%) died pre-operatively (typical:8% versus atypical:3%; p = 0.32). Non-fatal pre-operative complications occurred more among those with atypical TCM(p < 0.001), specifically cardiac arrest (typical:5% versus atypical:32%) and respiratory failure (9% versus 24%; both p < 0.05). Overall, 98 underwent surgery, majority undergoing laparoscopic adrenalectomy (81%); similar among the subtypes(p = 0.71). No robust data was provided on short-term outcomes, although two patients suffered from post-operative complications.

CONCLUSION

Although quite similar in presentation to either standalone TCM or PCC, PCC-TCM seems to be associated with a higher degree of morbidity and mortality. The atypical PCC-TCM subgroup seems to have a more severe course with possibly a poorer outcome. Further research is needed to make more reliable inferences.

Surgical management of anterior sacral meningoceles: an illustrated case series and review of the literature

BACKGROUND

Anterior sacral meningocele (ASM) is an uncommon variant of spinal dysraphism. Surgical correction for this condition is challenging and optimal corrective approaches are uncertain.

OBJECTIVE

To share our experience of managing this rare condition using the posterior trans-sacral approach and provide a contemporary review of the literature.

METHODS

Retrospective review of case notes, operative records, and imaging of eligible patients treated via the posterior trans-sacral approach between 2006 and 2020 at our regional neurosciences centre.

RESULTS

Three patients, two females and one male with a mean age of 30 years (range 16-38), were treated. Presenting symptoms included lower abdominal pain and recurrent miscarriages. Patients underwent corrective surgery using the posterior approach involving a sacral laminectomy, durotomy and closure of the communicating fistula. A single patient required reoperation due to early recurrence. Another patient proved challenging because of a very large sacral fistula and required two procedures due to the development of high-pressure headaches secondary to a recurrence. All patients improved symptomatically postoperatively and remained symptom free at the last clinic follow-up and have been discharged. Following review of the literature, only two other non-syndromic cases have been described.

CONCLUSIONS

ASM is an uncommon congenital abnormality, typically presenting with mass effect symptoms secondary to a presacral cystic mass. Surgical management using a posterior approach to close the meningeal sac is feasible and less invasive than an anterior approach. Long term clinical outcomes in our series were satisfactory.

Pediatric Vagus Nerve Stimulation: Case Series Outcomes and Future Directions

BACKGROUND

Vagus nerve stimulation (VNS) is a neuromodulatory procedure most extensively studied as an adjunct to medically refractory epilepsy. Despite widespread adoption and decades of clinical experience, clinical predictors of response to VNS remain unclear.

OBJECTIVE

To evaluate a retrospective cohort of pediatric patients undergoing VNS at our institution to better understand who may benefit from VNS and identify factors which may predict response to VNS.

METHODS

We conducted a retrospective cohort study examining pediatric patients undergoing VNS over nearly a 20-year span at a single institution. Presurgical evaluation, including demographics, clinical history, and diagnostic electroencephalogram, and imaging findings were examined. Primary outcomes included VNS response.

RESULTS

Two hundred ninety-seven subjects were studied. The mean age at surgery was 10.1 (SD = 4.9, range = 0.8-25.3) years; length of follow-up was a mean of 4.6 years (SD = 3.5, median = 3.9 years, range 1 day-16.1 years). There was no association between demographic factors, epilepsy etiology, or genetic basis and VNS outcomes. There was an association between reduction in main seizure type with positive MRI finding. Of all MRI findings analyzed, brain atrophy was significantly associated with worse VNS outcomes, whereas dysplastic hippocampus and chronic periventricular leukomalacia findings were found to be associated with improved outcomes. Increased seizure semiology variability and seizure type were also associated with improved seizure outcomes.

CONCLUSION

Predicting response to VNS remains difficult, leading to incompletely realized benefits and suboptimal resource utilization. Specific MRI findings and increased seizure semiology variability and type can help guide clinical decision making and patient counseling.

Flow Diversion as Destination Treatment of Intracranial Mycotic Aneurysms: A Retrospective Case Series

BACKGROUND

Mycotic aneurysms represent a rare type of intracranial aneurysm. Treatment options usually consist of coiling, clipping, or liquid embolization. Data regarding outcomes after flow diversion of mycotic aneurysms are sparse.

OBJECTIVE

To present a single-center case series regarding our experience with FD as definitive treatment for ruptured mycotic aneurysms initially treated with coil embolization.

METHODS

We retrospectively reviewed a prospectively maintained database of all cerebrovascular procedures performed at a single institution between 2017 and 2021 for cases that used FD for the management of intracranial mycotic aneurysms. Prospectively collected data included patient demographics, medical history, rupture status, aneurysm morphology, aneurysm location, and periprocedural complications. The main outcomes included neurological examination and radiographic occlusion rate on cerebral digital subtraction angiography.

RESULTS

Three patients with 4 ruptured mycotic aneurysms that were initially treated with coil embolization were identified that required retreatment. The aneurysms were located along the middle cerebral artery bifurcation (n = 2), posterior cerebral artery P1/2 junction (n = 1), and basilar artery apex (n = 1), which all demonstrated recurrence after initial coil embolization. Successful retreatment using flow diverting stents was performed in all 3 patients. At the last angiographic follow-up, all aneurysms demonstrated complete occlusion. No patients suffered new periprocedural complications or neurological deficits after FD.

CONCLUSION

Flow-diverting stents may be an effective treatment option for intracranial mycotic aneurysms that are refractory to previous endovascular coiling. Future studies are warranted to establish the associated long-term safety and clinical efficacy.

Intraoperative Ultrasonography in Endoscopic Approaches for Orbital Lesions: A Single-Center Case Series

BACKGROUND

Recently, endoscopic approaches for orbital lesions have been proposed. Their results seem promising; however, orbital surgery remains challenging with possible significant morbidity, mostly because of orbital structures manipulation. Ultrasonography is an innovative intraoperative imaging technique that can assist the surgeon in these approaches.

OBJECTIVE

To assess the role of intraoperative ultrasound (IOUS) in endoscopic orbital surgery.

METHODS

All consecutive patients with orbital tumors operated in our institution through an endoscopic approach with IOUS have been prospectively collected from 2019 to May 2021.

RESULTS

Fifteen patients were included. Based on tumor location, evaluated on preoperative MRI, the endoscopic endonasal approach was preferred in 7 tumors in medial quadrants while the endoscopic transpalpebral in 8 lateral ones. During surgery, IOUS allowed us to identify the tumors and the most relevant anatomic structures in all cases. Time spent for IOUS preparation before the first scan was 8 ± 6 minutes on average, and each intraoperative scan took approximately 30 to 120 seconds. Gross tumor removal was achieved in 8 patients, subtotal in 3, while in 4 patients, surgery was limited to a biopsy. No surgical complications were observed.

CONCLUSION

IOUS has allowed us to localize the lesion and to identify the straighter surgical corridor and assess the tumor resection, effectively helping the surgeon and potentially reducing operative complications. This tool provides a real-time image, not affected by the orbital structures shift, which can be dynamically assessed multiple times during surgery. However, it is hampered by the need of specific training and possible artifacts.

Bloqueio do plano do músculo serrátil guiado por ultrassonografia associado à sedação venosa como técnica anestésica em cirurgia de linfadenectomia axilar: uma série de casos prospectiva

RESUMO A linfadenectomia axilar é um procedimento cirúrgico padrão para tratamento de tumores de pele e partes moles no estádio III e usualmente é realizada sob anestesia geral. A presente serie de casos prospectiva tem por objetivo investigar a viabilidade da realização da linfadenectomia axilar com o uso do bloqueio do plano do músculo serrátil anterior associado a sedação endovenosa. Foram incluídos 15 pacientes no estudo. Os participantes foram recrutados e avaliados durante consulta pré-anestésica ambulatorial, acompanhados durante o dia da cirurgia, no primeiro e no trigésimo dias de pós-operatório. O bloqueio foi realizado anterior ao músculo serrátil anterior ao nível da quarta costela na linha axilar média. A sedação foi realizada com o uso de propofol, fentanil, dexmedetomidina e dextrocetamina. Não houve necessidade de conversão para anestesia geral em nenhum paciente. Os cirurgiões apresentaram resposta altamente positiva quando questionados sobre a técnica anestésica, considerando na maior parte dos casos “indistinguível” da anestesia geral. A mediana (intervalo interquartil) da dor em repouso em todos os momentos avaliados foi 0 (0-0). Além disso, nenhum paciente desenvolveu náuseas, vômitos, instabilidade hemodinâmica ou qualquer complicação relacionada à técnica empregada. O bloqueio do plano do músculo Serrátil anterior associado a sedação venosa se mostrou viável para execução de linfadenectomia axilar, entretanto ensaios clínicos adicionais são necessários para avaliar potenciais vantagens em comparação com outras técnicas.

Revisiting destructive operations to prevent second stage caesarean section in COVID times: A case series

Destructive operations diminish the bulk of the foetus for facilitating vaginal delivery. Procedures such as craniotomy or decapitation can be carried out to deliver a dead baby in appropriately selected cases. Ours is a retrospective case series at a single tertiary facility during the first wave of the COVID pandemic. From July 2020 to January 2021, six destructive operations (five craniotomies and one decapitation) were performed in women who had arrest of descent in the second stage of labour but had intrapartum foetal demise. The average operative time was 30 minutes with a mean hospital stay of 4.3 days, which was significantly less than CS, and with much less morbidity. None of these women had significant post-partum haemorrhage or sepsis. Destructive procedures should be considered for better obstetric future of the patient, and a lesser burden on the health facility. What was practiced in COVID times should be extended beyond.

Cochlear Implantation Following Transcanal Infrapromontorial Approach for Vestibular Schwannoma: A Case Series

Background: Cochlear implantation (CI) following endoscopic transcanal infrapromontorial vestibular schwannoma (VS) dissection is a feasible intervention in intracanalicular VS, with minimal extension into the cerebellopontine angle, but no audiologic results have ever been reported in the literature. Methods: From 2015 to 2021 in the Otorhynolaryngology Departments of Modena and Verona, three patients underwent this intervention. All were suffering from sporadic left-sided intracanalicular Koos I VS. Intraoperative electrically evoked auditory brainstem responses and electrophysiological measurements were performed before and after the placement of the electrode array, respectively. Since device activation one month after the surgery, each patient was followed up with audiometric tests, data logging, electrode impedance measurements and neural response telemetry performed at each scheduled fitting session at 15 days and 3, 6, 12 and 24 months. Results: Only in patient No. 3, an auditory benefit was observed and still evident even 36 months after activation. Impedances increased progressively in patient No. 1 and a benefit was never reported. Patient No. 2 left the follow-up for worsening comorbidities. Conclusions: CI following transcanal infrapromontorial VS resection is a beneficial intervention. The residual cochlear nerve after the tumour dissection and the course of electrophysiological measurements in the postoperative period were the main predictive factors for audiological outcomes.

Analysis of Patient Cues in Asynchronous Health Interactions: Pilot Study Combining Empathy Appraisal and Systemic Functional Linguistics

BACKGROUND

Lifestyle-related diseases are among the leading causes of death and disability. Their rapid increase worldwide has called for low-cost, scalable solutions to promote health behavior changes. Digital health coaching has proved to be effective in delivering affordable, scalable programs to support lifestyle change. This approach increasingly relies on asynchronous text-based interventions to motivate and support behavior change. Although we know that empathy is a core element for a successful coach-user relationship and positive patient outcomes, we lack research on how this is realized in text-based interactions. Systemic functional linguistics (SFL) is a linguistic theory that may support the identification of empathy opportunities (EOs) in text-based interactions, as well as the reasoning behind patients' linguistic choices in their formulation.

OBJECTIVE

This study aims to determine whether empathy and SFL approaches correspond and complement each other satisfactorily to study text-based communication in a health coaching context. We sought to explore whether combining empathic assessment with SFL categories can provide a means to understand client-coach interactions in asynchronous text-based coaching interactions.

METHODS

We retrieved 148 text messages sent by 29 women who participated in a randomized trial of telecoaching for the prevention of gestational diabetes mellitus (GDM) and postnatal weight loss. We conducted a pilot study to identify users' explicit and implicit EOs and further investigated these statements using the SFL approach, focusing on the analysis of transitivity and thematic analysis.

RESULTS

We identified 164 EOs present in 42.37% (3478/8209) of the word count in the corpus. These were mainly negative (n=90, 54.88%) and implicit (n=55, 60.00%). We distinguished opening, content and closing messages structures. Most of the wording was found in the content (n=7077, 86.21%) with a declarative structure (n=7084, 86.30%). Processes represented 22.4% (n=1839) of the corpus, with half being material (n=876, 10.67%) and mostly related to food and diet (n=196, 54.92%), physical activity (n=96, 26.89%), and lifestyle goals (n=40, 11.20%).

CONCLUSIONS

Our findings show that empathy and SFL approaches are compatible. The results from our transitivity analysis reveal novel insights into the meanings of the users' EOs, such as their seek for help or praise, often missed by health care professionals (HCPs), and on the coach-user relationship. The absence of explicit EOs and direct questions could be attributed to low trust on or information about the coach's abilities. In the future, we will conduct further research to explore additional linguistic features and code coach messages.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620001240932; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380020.

Oesophageal neuroendocrine tumours-case series of a rare malignancy

Oesophageal neuroendocrine neoplasms (NENs) are rare tumours. Neuroendocrine carcinomas (NECs) are the highest grade of NENs, with aggressive biological behaviour and poor outcomes. No standardized treatment pathways exist for these tumours, with management being individualized based on patient and tumour factors. We present five cases, four men and one women between 63 and 68 years old, who were diagnosed with symptomatic primary oesophageal NECs. Three were diagnosed with localized disease, and two were diagnosed with metastatic disease. Endoscopy, biopsy and staging scan results are outlined. Two patients received neoadjuvant chemotherapy. Three patients with localized disease underwent oesophagectomy. Two of these patients received neoadjuvant chemotherapy. Four patients have succumbed to their disease, with a median survival following a diagnosis of 18 months (5-34 months). This case series highlights the variability of presentation and stage at diagnosis of oesophageal NECs. Multimodal treatment is commonly utilized; however, outcomes are universally poor. Further research is required to determine the optimal treatment regimen for oesophageal NENS.

Brain aneurysm rupture during mechanical thrombectomy for large vessel occlusion: Technical case series and complication avoidance strategies

Endovascular therapy became the mainstream treatment for patients with acute stroke due to emergent large vessel occlusion (LVO). With increasing number of interventions, it is not uncommon for incidental vascular pathologies to be found during mechanical thrombectomy. Overall, intracranial aneurysms can occur in up to 4% of the population, but previous studies suggest a slightly higher prevalence of intracranial aneurysms in stroke patients as they may share common risk factors. We report on three patients with acute stroke secondary to LVO undergoing mechanical thrombectomy with brain aneurysms incidentally discovered and discuss the potential implications and technical considerations of performing revascularization in these scenarios. In the first case, a patient treated with stent-retriever and aspiration developed a carotid-cavernous fistula without clinical repercussion. The second case illustrates an internal carotid artery posterior communicating segment aneurysm rupture with a massive subarachnoid hemorrhage. The third case exemplifies an unruptured middle cerebral artery bifurcation aneurysm related to an M2 occlusion managed with a different strategy, avoiding aneurysm rupture. Intraprocedural aneurysm rupture is a potential complication during mechanical thrombectomy, especially when anatomical challenges are present. Interventionalists should be aware of the potential risk and constraints in this setting in order to mitigate adverse events.

Posterior Quadrant Disconnection Procedure for Intractable Epilepsy: A Case Series of 5 Young Pediatric Patients

BACKGROUND

Posterior quadrant disconnection (PQD) has been described as a treatment for patients with refractory posterior quadrant subhemispheric epilepsy. Surgical outcomes are difficult to interpret because of limited literature.

OBJECTIVE

To provide insight regarding the operative technique and postsurgical seizure freedom in young pediatric patients who underwent surgical disconnection for the treatment of posterior quadrant subhemispheric epilepsy at our institution.

METHODS

The authors retrospectively analyzed a series of 5 patients who underwent PQD between 2019 and 2021. Charts were reviewed for preoperative workup including noninvasive/invasive testing, operative reports, and postoperative follow-up data which included degree of seizure freedom, completion of disconnection, and complications.

RESULTS

Five patients were included in this series. The median age at seizure onset was 12 months (range 3-24 months), and the median age at surgery was 36 months (range 22-72 months). Histopathology confirmed focal cortical dysplasia in 3 of 5 patients (2 patients with type IB; 1 with type IIID). The average length of follow-up after surgery was 16.8 months (range 12-24 months). All patients underwent complete disconnection of the posterior quadrant without complications. Four of 5 patients (80%) had Engel score of I, while the remaining patient had an Engel score of IIB.

CONCLUSION

Our early results demonstrate that complete PQD can be successful at providing excellent seizure freedom and functional outcomes in carefully selected young pediatric patients who have concordant seizure semiology, noninvasive/invasive testing, and imaging findings with primary seizure onset zone within the ipsilateral posterior quadrant. Meticulous surgical planning and thorough understanding of the surgical anatomy and technique are critical to achieving complete disconnection.

Blunt Traumatic Tracheobronchial Injury: a Clinical Pathway

Background

Motor vehicle collisions (MVC) are a major burden on healthcare systems. Saudi Arabia is one of the countries with a high mortality rate of MVC. Blunt tracheobronchial injuries are rare; however, it is a catastrophic event that requires a high center of care. Lack of experience and advanced faculty prompt early stabilization and transfer of the victim for advanced care. Due to the uncertainty of management of these injuries, we would like to share our experience in dealing with such injuries.

Objective

To address the difficulties in initial management and transfer of patient with blunt traumatic tracheobronchial injuries.

Methods

This is a single-center retrospective case-series study including patients admitted as cases of trauma including all age groups with blunt acute tracheobronchial injuries confirmed by imaging or bronchoscope.

Results

In our study, four patients with tracheobronchial injuries were identified, and a retrospective analysis was performed. Two of the males and one of the females are adults, while the other two are pediatrics. Two of them have a right main bronchial injury and the other two have a left main bronchial injury. Posterolateral thoracotomy and bronchial anastomosis were performed on all four patients and were followed up.

Conclusion

In Saudi Arabia, blunt trauma is a prevalent type of injury, although tracheobronchial injuries are uncommon. In the event of trauma, a high index of suspicion of tracheobronchial injuries in a high mechanism injury warrants prompt treatment. Due to a lack of experienced and specialized hands in this field, management may be delayed, and eventually lead to unfavorable outcomes, hence we thought of a guide to facilitate the decision-making.

Pedicle screw placement safety with the aid of patient-specific guides in a case series of patients with thoracic scoliosis

PURPOSE

Pedicle screw (PS) placement in thoracic scoliotic deformities can be challenging due to altered vertebral anatomy; malposition can result in severe functional disability or inferior construct stability. Three-dimensional (3D) printed patient-specific guides (PSGs) have been recently used to supplement other PS placement techniques. We conducted a single-center, retrospective observational study to assess the accuracy of PS placement using PSGs in a consecutive case series of pediatric and adult patients with thoracic scoliosis.

METHODS

We analyzed the data of patients with thoracic scoliosis who underwent PS placement using 3D-printed PSG as a vertebral cannulation aid between June 2013 and July 2018. PS positions were determined via Gertzbein-Robbins (GR) and Heary classifications on computed tomography images. We determined the concordance of actual and preoperatively planned PS positions and defined the technique learning curve using a receiver-operating characteristic (ROC) curve.

RESULTS

We performed 362 thoracic PS placement procedures in 39 consecutive patients. We classified 352 (97.2%), 2 (0.6%), and 8 (2.2%) screws as GR grades 0 (optimal placement), I, and II, respectively. The average instrumented PS entry point offsets on the X- and Y-axes were both 0.8 mm, and the average differences in trajectory between the planned and the actual screw placements on the oblique sagittal and oblique transverse planes were 2.0° and 2.4°, respectively. The learning process was ongoing until the first 12 PSs were placed.

CONCLUSIONS

The accuracy of PS placement using patient-specific 3D templates in our case series exceeds the accuracies of established thoracic PS placement techniques.

Evaluation of outcome of different neurosurgical modalities in management of cervical dystonia

Background

Cervical dystonia is the most common form of focal dystonia and is managed by multiple modalities including repeated botulinum toxin injections, in addition to medical treatment with anticholinergics, muscle relaxants, and physiotherapy. However, surgical interventions could be beneficial in otherwise refractory patients. This study aims to report our experience in the neurosurgical management of cervical dystonia and evaluate patient outcomes using reliable outcome scores for the assessment of patients with cervical dystonia and possible complications. This case series study was conducted on 19 patients with cervical dystonia of different etiologies who underwent surgical management [ten patients underwent selective peripheral denervation, five patients underwent pallidotomy, and four patients underwent bilateral globus pallidus internus (GPi) deep brain stimulation (DBS)] in the period between July 2018 and June 2021 at Ain Shams University Hospitals, Cairo, Egypt. With the assessment of surgical outcomes using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and the Tsui scale 6 months postoperatively.

Results

Surgical management of patients with cervical dystonia of either primary or secondary etiology was associated with significant improvement in head and neck postures after 6 months without major complications associated with the different surgical procedures. The mean improvement in total TWSTRS and Tsui scores were 51.2% and 64.8%, respectively, compared with preoperative scores, while the mean improvement in the TWSTRS subscales (severity, disability, and pain) were 40.2%, 66.9%, and 58.3%, respectively.

Conclusion

Cervical dystonia patients in whom non-surgical options have failed to alleviate their symptoms can be managed surgically leading to significant improvements with minimal adverse effects. However, surgical treatment should be tailored according to several factors including but not limited to the etiology, pattern of dystonic activity, and comorbidities. Therefore, management should be tailored to achieve long-term improvement with minimal risk of complications.

Accessory columellas: A case series on surgical method and short-term postoperative course

PURPOSE

Accessory columellas are rare congenital anomalies characterized by skin appendage in the columella of the nostril. Case reports are scattered, but there are few descriptions about the clinical features and surgical course.

METHOD

In this study, 3 patients with 4 lesions were identified (2013-2020). They were morphologically classified, and the accompanying nose deformity, surgical procedure, and postoperative course were examined.

RESULTS

According to the morphologic classification, 1 lesion was of the sessile-lobed type, 2 lesions were of the sessile-nodular type, and 1 lesion was of the pedunculated-ovoid type. In terms of accompanying nose deformities, 1 lesion had a wide nasal columella, and 1 lesion had an enlarged left nostril due to a depression at the base of the lesion. Simple ablations were performed in 2 of the lesions, and plastic procedures were performed in the 2 lesions with an accompanying nose deformity.

CONCLUSION

As in our cases, accessory columellas may have a variety of appearances and accompanying deformities. The surgical procedure must be considered according to the case. In addition, any changes due to growth must be observed and taken into consideration when they are reoperated.

Influence of vestibular depth on the outcomes of root coverage therapy: A prospective case series study

BACKGROUND

The purpose of this study was to investigate the influence of vestibular depth (VD) on the outcomes of root coverage therapy.

METHODS

Patients presenting gingival recession defects (GRD) with a minimum depth of 2 mm underwent root coverage therapy consisting of a coronally advanced flap plus a connective tissue graft (CAF + CTG). Clinical examinations were performed, and intraoral scans were obtained at baseline, 3 and 6 months after surgery to assess changes in probing depth (PD), keratinized tissue width (KTW), recession depth (RD), GRD area, marginal gingival thickness (MGT), and VD. The influence of VD on percentage of root coverage (%RC) and the likelihood of achieving complete root coverage (CRC) were explored.

RESULTS

A total of 20 patients were enrolled, and 44 teeth were treated. RD decreased and MGT increased in all treated sites. At 6 months, mean %RC was 87.47 ± 18.37 and CRC was observed in 61.4% of sites. Mean baseline VD was 7.33 ± 2.67 mm. Mean VD reduction from baseline to 6 months was 1.98 ± 1.27 mm. %RC and CRC were significantly correlated with baseline VD. Each additional 1 mm of baseline VD implied a gain of 6.58% for %RC and increased 2.75 times the probability of achieving CRC. Narrow baseline KTW and mandibular arch location were associated with inferior treatment outcomes.

CONCLUSION

Lower %RC and likelihood of achieving CRC can be expected after root coverage therapy via CAF + CTG in sites presenting a shallow vestibulum.

A rare presentation of appendicitis contained within an incisional hernia post loop ileostomy reversal - A case report

INTRODUCTION AND IMPORTANCE

Appendicitis within an incisional hernia is rare, with current literature describing a small number of cases, occurring through a variety of surgical incisions. We describe a case of appendicitis contained within an incisional hernia following reversal of a loop ileostomy, on a background of previous sigmoid cancer resection. This is the second such case we were able to identify on literature review.

CASE PRESENTATION

A 45 year old man presented with one day of migratory abdominal pain, predominantly focused at a tender, irreducible lump in his right lower quadrant, underlying the scar from previous reversal of loop ileostomy. CT on admission revealed an incisional hernia, containing an inflamed appendiceal tip. He underwent an uncomplicated laparoscopic appendicectomy and primary suture closure of the hernia defect, and was discharged the following day. Acute appendicitis was confirmed on histopathology.

DISCUSSION

Placement of a defunctioning ileostomy is common in the management of colonic cancers, and incisional hernias are a common complication. It is however rare for an appendix to be contained within a hernia sac, and even rarer for appendicitis to develop in this setting. As a result, the presentation of this condition may mimic that of an incarcerated or strangulated incisional hernia, with pre-operative diagnosis typically relying on diagnostic imaging.

CONCLUSION

Incisional hernia appendicitis is rare and presents a diagnostic challenge. Early recognition of this dual pathology is necessary to allow for prompt surgical management of both the appendicitis and hernia, as well as guiding the approach for hernia repair.

Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Management of Low-Grade Gliomas and Radiation Necrosis: A Single-Institution Case Series

BACKGROUND

Laser interstitial thermal therapy (LITT) has emerged as a minimally invasive treatment modality for ablation of low-grade glioma (LGG) and radiation necrosis (RN).

OBJECTIVE

To evaluate the efficacy, safety, and survival outcomes of patients with radiographically presumed recurrent or newly diagnosed LGG and RN treated with LITT.

METHODS

The neuro-oncological database of a quaternary center was reviewed for all patients who underwent LITT for management of LGG between 1 January 2013 and 31 December 2020. Clinical data including demographics, lesion characteristics, and clinical and radiographic outcomes were collected. Kaplan-Meier analyses comprised overall survival (OS) and progression-free survival (PFS).

RESULTS

Nine patients (7 men, 2 women; mean [SD] age 50 [16] years) were included. Patients underwent LITT at a mean (SD) of 11.6 (8.5) years after diagnosis. Two (22%) patients had new lesions on radiographic imaging without prior treatment. In the other 7 patients, all (78%) had surgical resection, 6 (67%) had intensity-modulated radiation therapy and chemotherapy, respectively, and 4 (44%) had stereotactic radiosurgery. Two (22%) patients had lesions that were wild-type IDH1 status. Volumetric assessment of preoperative T1-weighted contrast-enhancing and T2-weighted fluid-attenuated inversion recovery (FLAIR) sequences yielded mean (SD) lesion volumes of 4.1 (6.5) cm³ and 26.7 (27.9) cm³, respectively. Three (33%) patients had evidence of radiographic progression after LITT. The pooled median (IQR) PFS for the cohort was 52 (56) months, median (IQR) OS after diagnosis was 183 (72) months, and median (IQR) OS after LITT was 52 (60) months. At the time of the study, 2 (22%) patients were deceased.

CONCLUSIONS

LITT is a safe and effective treatment option for management of LGG and RN, however, there may be increased risk of permanent complications with treatment of deep-seated subcortical lesions.

Cutaneous Blastomycosis Presenting as a Nonhealing Wound in the Northeast United States: A Case Report

Primary cutaneous blastomycosis is a rare presentation of infection caused by direct inoculation of a wound. We present a 61-year-old male with an extensive history of wound dehiscence and wound care noncompliance after a bite from a brown recluse spider on the left thigh while on vacation in Cape Cod in September of 2020. After antibiotic therapy and culture, treatment involved debridement, split thickness skin grafting, strict wound vacuum-assisted closure care, and oral itraconazole. This brief demonstrates a case of blastomycosis arising from trauma in a non-endemic region for infection and serves as an example of successful management of the longstanding wound.

Spontaneous obliteration of brain arteriovenous malformations: illustrative cases

BACKGROUND

Spontaneous angiographic obliteration of a brain arteriovenous malformation (AVM) is considered a rare outcome, with most cases in the literature related to prior hemorrhage in small brain AVMs. The authors present a prospective, single center, consecutive case series. The clinical course and radiographic features of four cases with spontaneous obliteration of brain AVM were analyzed.

OBSERVATIONS

The median age of patients in this series was 47.6 years, with an equal gender split. The median maximum brain AVM diameter was 2 cm. The median time to spontaneous obliteration was 26 months, with hemorrhage preceding this in three out of four cases and a prolonged latency in the only case with a nidus size larger than 3 cm and no hemorrhage.

LESSONS

The present study provides additional information to allow clinicians to counsel patients about the rare outcomes of conservative management. This work extends our understanding of when this phenomenon can occur by reporting on the differences associated with spontaneous obliteration of larger AVMs.