A Case of Successful Explantation of an Infected Fenestrated Aortic Endograft Using a Composite Xeno/Biosynthetic In Situ Reconstruction

Introduction

Graft infections after open or endovascular repair can be devastating, and their treatment is always challenging. For thoraco-abdominal and abdominal aortic aneurysms, fenestrated and branched endografts are used increasingly. Because of the involved materials and anatomy, infective complications can be even more complex.

Report

One year after double fenestrated endovascular endorepair for a type Ia endoleak after standard endovascular repair, a 77 year old patient developed clinical signs for sepsis at an external clinic. As his clinical situation deteriorated, he was then referred to the centre, where an infection focus search revealed a Staphylococcus aureus bacteraemia, and computed tomography (CT), and fludeoxyglucose positron emission tomography CT showed signs of endograft infection. Trestment by endograft explantation followed, and in situ reconstruction with a composite xeno/biosynthetic graft was performed. Through a median laparotomy, endograft explantation as well as in situ reconstruction were technically successful, and sepsis control was achieved under concomitant anti-infective therapy. After a 48 day hospital stay (22 days in the intensive care unit), the patient was discharged to a rehabilitation clinic. After three months of uneventful follow up, precision dual antibiotic therapy with ciprofloxacin and rifampicin was stopped. Four year follow up confirmed freedom from infection and a properly functioning aortic reconstruction.

Discussion

After fenestrated stent graft procedures, successful late conversion is challenging and is known to correlate with high morbidity and mortality. The present case confirms the feasibility of this approach, even in patients with sepsis, with good results.

Advancing Inflammatory Bowel Disease Treatment by Targeting the Innate Immune System and Precision Drug Delivery

Inflammatory bowel disease (IBD), encompassing Crohn's disease and ulcerative colitis, involves chronic inflammation of the gastrointestinal tract. Current immune-modulating therapies are insufficient for 30-50% of patients or cause significant side effects, emphasizing the need for new treatments. Targeting the innate immune system and enhancing drug delivery to inflamed gut regions are promising strategies. Neutrophils play a central role in IBD by releasing reactive oxygen species (ROS) and neutrophil extracellular traps (NETs) -DNA-based structures with cytotoxic proteins-that contribute to mucosal damage and inflammation. Recent studies linking ROS production, DNA repair, and NET formation have identified NETs as potential therapeutic targets, with preclinical models showing positive outcomes from NET inhibition. Innovative oral drug delivery systems designed to target gut inflammation directly-without systemic absorption-could improve treatment precision and reduce side effects. Advanced formulations utilize properties such as particle size, surface modifications, and ROS-triggered release to selectively target the distal ileum and colon. A dual strategy that combines a deeper understanding of IBD pathophysiology to identify inflammation-related therapeutic targets with advanced drug delivery systems may offer significant promise. For instance, pairing NET inhibition with ROS-responsive nanocarriers could enhance treatment efficacy, though further research is needed. This synergistic approach has the potential to greatly improve outcomes for IBD patients.

Vibrio vulnificus-A Review with a Special Focus on Sepsis

Vibrio vulnificus (V. vulnificus) is a Gram-negative, halophilic bacillus known for causing severe infections such as gastroenteritis, necrotizing fasciitis, and septic shock, with mortality rates exceeding 50% in high-risk individuals. Transmission occurs primarily through the consumption of contaminated seafood, exposure of open wounds to infected water, or, in rare cases, insect bites. The bacterium thrives in warm, brackish waters with high salinity levels, and its prevalence is rising due to the effects of climate change, including warming ocean temperatures and expanding coastal habitats. High-risk populations include individuals with underlying conditions such as chronic liver disease, diabetes, or immunosuppression, which heighten susceptibility to severe outcomes. The pathogenicity of V. vulnificus is mediated by an array of virulence factors, including hemolysins, proteases, and capsular polysaccharides, as well as mechanisms facilitating iron acquisition and immune system evasion. Clinical manifestations range from localized gastrointestinal symptoms to life-threatening systemic infections such as septicemia. Rare but severe complications, including pneumonia and meningitis, have also been reported. Treatment typically involves the use of doxycycline in combination with third-generation cephalosporins, although the emergence of multidrug-resistant strains is an escalating concern. Alternative therapeutic approaches under investigation include natural compounds such as resveratrol and the application of antimicrobial blue light. For necrotizing infections, prompt and aggressive surgical intervention remains essential to improving patient outcomes. As global temperatures continue to rise, understanding the epidemiology of V. vulnificus and developing innovative therapeutic strategies are critical to mitigating its growing public health impact.

Retrospective Analysis Comparing Lung-RADS v2022 and British Thoracic Society Guidelines for Differentiating Lung Metastases from Primary Lung Cancer

Background and Objectives: The current study aimed to compare the effectiveness of the Lung Imaging Reporting and Data System (Lung-RADS) Version 2022 and the British Thoracic Society (BTS) guidelines in differentiating lung metastases from de novo primary lung cancer on CT scans in patients without prior cancer diagnosis. Materials and Methods: This retrospective study included 196 patients who underwent chest CT scans between 2015 and 2022 without a known history of cancer but with detected pulmonary nodules. CT images characterized nodules based on size, number, location, margins, attenuation, and growth patterns. Nodules were classified according to Lung-RADS Version 2022 and BTS guidelines. Statistical analyses compared the sensitivity and specificity of Lung-RADS and BTS guidelines in distinguishing metastases from primary lung cancer. Subgroup analyses were conducted based on nodule characteristics. Results: Of the 196 patients, 148 (75.5%) had de novo primary lung cancer, and 48 (24.5%) had lung metastases from occult primary tumors. Lung-RADS Version 2022 demonstrated higher specificity than BTS guidelines (87.2% vs. 72.3%, p < 0.001) while maintaining similar sensitivity (91.7% vs. 93.8%, p = 0.68) in differentiating lung metastases from primary lung cancer. Lung metastases were more likely to present with multiple nodules (81.3% vs. 18.2%, p < 0.001), lower lobe distribution (58.3% vs. 28.4%, p < 0.001), and smooth margins (70.8% vs. 20.3%, p < 0.001), whereas primary lung cancers were associated with solitary nodules, upper lobe location, and spiculated margins. Conclusions: Lung-RADS Version 2022 provides higher specificity than the BTS guidelines in differentiating lung metastases from primary lung cancer on CT scans in patients without prior cancer diagnosis. Recognizing characteristic imaging features can improve diagnostic accuracy and guide appropriate management.

Case Report: Winkelmann hip rotationplasty as a last-resort solution

Background

Rotationplasty, an invasive surgery, serves as an alternative to amputation in pediatric orthopedic oncology. It is currently applied in broader cases (e.g., infection, trauma, or malignant tumors). Winkelmann Type BII rotationplasty is a rare procedure with limited literature. Furthermore, no description of rotationplasties where the femur is attached to the sacroiliac joint has been published to date.

Methods

Between September 2022 and March 2023, three patients underwent Type BII rotationplasty. We used the Clavien-Dindo classification to describe postoperative complications and the musculoskeletal tumor society score (MSTS) for functional result assessments.

Results

One patient suffered from multiple complications during the first 6 months postoperatively, one presented a single complication, and one had no complications after 4 and 3 months postoperatively, respectively. Two patients could walk pain-free with the help of crutches. One patient developed a crack on the femur, which did not require surgical revision. They all achieved satisfactory joint amplitudes of at least 50° in passive hip flexion. Unfortunately, one of the patients suffered from lung metastases.

Conclusions

Winkelmann's Type BII rotationplasty is a reliable alternative to hindquarter amputation. Furthermore, we demonstrated that complete resection of the iliac wing and femur fixation through the sacroiliac joint is feasible.

Use of social media for academic and professional purposes by gynecologic oncologists

OBJECTIVE

To investigate the prevalence and patterns of social media use among gynecologic oncologists for professional and academic purposes.

METHODS

A prospective online survey between November and December 2022 targeted gynecologic oncology practitioners (gynecologic oncologists, surgical oncologists, medical oncologists, radiation/clinical oncologists, and onco-pathologists/pathologists). The survey, distributed via various social media platforms, included 40 questions to capture qualitative and quantitative data on social media use.

RESULTS

Of 131 respondents from 32 countries, 106 (80.9%) were gynecologic oncologists and affiliated with academic institutions (84.7%). Facebook (n=110, 83.9%), Twitter (n= 108, 82.4%), and Instagram (n=100, 76.3%) were the most used platforms. Respondents used social media to stay updated (n=101, 77.1%), network (n=97, 74%), learn about conferences and webinars (n=97, 74%), and engage in academic discussions (n=84, 64.1%). Following the COVID-19 pandemic, 100/129 (77.5%) reported increased social media use. However, only 32 (24.4%) used it to connect with patients, and concerns were raised about privacy and the need for separate professional and personal accounts. A quarter of respondents hesitated to share their opinions on social media due to the fear of controversy, with 26 (20%) experiencing cyberbullying, yet 120/130 (92.3%) believed it enabled junior professionals to express their views. Concerns about differentiating valid content, information reliability, and the professional perception of sourcing knowledge from social media were noted. Gender, age, specialty, and income level influenced patterns of social media use, with variations in preferences for platforms, content engagement, and purposes, highlighting a complex landscape of social media interaction among gynecologic oncologists.

CONCLUSION

While the use of social media among gynecologic oncologists is prevalent, particularly for academic and professional development, challenges such as cyberbullying, privacy concerns, and the need for formal training in social media navigation persist. Tailored training programs and guidelines could enhance social media's effective and ethical use in this field, promoting a safe environment for professional expression and engagement.

Latent profiles and determinants of postoperative sleep quality in elective surgery patients

It is crucial to determine the potential subgroups of sleep disturbances in patients undergoing elective surgery based on the importance of symptom clusters and individual characteristics in order to develop targeted symptom management plans. This study explored the potential categories of postoperative sleep disturbances in patients undergoing elective surgery through latent profile analysis, and explored the influencing factors of each category. A total of 400 eligible elective surgery patients were included in the analysis, and three potential subgroups were identified: mild sleep disturbance group (c1 = 140,35.0%), moderate sleep sleep disturbance group (c2 = 177,44.2%), and severe sleep disturbance group (c3 = 83,20.8%). It was found that the higher the BMI, the greater the probability of patients belonging to the moderate sleep disturbance group (OR = 1.114, P = 0.002) and the severe sleep disturbance group (OR = 1.258, P < 0.001),the longer the duration of anesthesia the greater the likelihood of patients belonging to the severe sleep disturbance group (OR = 1.004,P = 0.011), the greater the pain the greater the probability of patients belonging to the moderate sleep disturbance group (OR = 1.590,P < 0.001) and severe sleep disturbance group (OR = 1.785,P < 0.001), and the higher the anxiety level the greater the probability that patients were in the moderate sleep disturbance group (OR = 1.135,P = 0.007) and severe sleep disturbance group (OR = 1.261,P < 0.001).

Prediction of the need for surgery in patients with unruptured abdominal aortic aneurysm based on SOFA score

OBJECTIVE

This retrospective study aimed to explore the association and clinical value of sequential organ failure assessment (SOFA) score on the predictors of adverse events in patients with unruptured abdominal aortic aneurysms (AAA).

METHODS

A total of 322 patients from Medical Information Mart for Intensive Care IV database were enrolled. Logistic regression was conducted to explore the association between SOFA and primary outcome (need for surgery, NFS). Receiver operating characteristic (ROC) and nomogram analyses were used to assess its performance for predicting NFS. We also explored the association and clinical value of SOFA on secondary outcomes including hospital length of stay (LOS), ICU-LOS, and in-hospital mortality by linear and logistic regression analyses, generalized additive model, ROC, and decision curve analysis.

RESULTS

Totally 291 patients underwent the surgery. High SOFA score significantly correlated with NFS both in crude and adjusted models (all P<0.05). SOFA had a relatively favorable prediction performance on NFS (AUC = 0.701, 95%CI: 0.596-0.802). After adjusting for related diseases, its prediction performance was increased. When SOFA was combined with lactate and gender, the model showed an AUC of 0.888 (95%CI: 0.759-1.000) and 0.3-0.9 prediction possibility. Further, the SOFA also showed significant relationship with hospital-LOS, ICU-LOS, and in-hospital mortality (all P<0.05), and exerted some value in the prediction of 7-day hospital-LOS (AUC = 0.637, 95%CI: 0.575-0.686) and in-hospital mortality (AUC = 0.637, 95%CI: 0.680-0.845).

CONCLUSIONS

SOFA score was related to the NFS and can be regarded as a useful indicator for predicting the NFS in patients with AAA.

The Impact of Hepatic Hydrothorax on the Outcome of Liver Cirrhosis: A Comparative Study

Introduction: Hepatic hydrothorax (HH) is a severe cirrhosis complication requiring early diagnosis and appropriate management. This study aimed to assess the impact of HH on the disease severity and mortality of cirrhotic patients and compare their clinical and biological profiles with those of patients without HH. Materials and Methods: This retrospective study involved 155 patients diagnosed with cirrhosis, of whom 31 had HH. The diagnosis of HH was based on imaging techniques such as X-ray, ultrasound, and thoracic CT scans. The severity of cirrhosis was evaluated using the Child-Pugh, MELD, MELD-Na, and MELD 3.0 scoring systems. Results: Of the included patients, 83.87% (n = 26) were men, with a 20% incidence of HH. The main etiology was chronic alcohol use. The pleural fluid localization revealed similar numbers of patients with bilateral and right pleural distribution. Patients with HH were predominantly classified in Child-Pugh-Turcotte class C. The MELD, MELD-Na, and MELD 3.0 scores had higher median values in the group of patients with hepatic hydrothorax. Still, death occurred at lower MELD scores when compared with cirrhotic patients without HH (MELD score > 22.5 for patients with HH vs. MELD > 32.5 for patients without HH). (The cirrhotic patients with HH presented lower serum albumin, cholesterol, and triglyceride levels and higher bilirubin, INR, and creatinine values. The mortality rate was higher in the group with HH-58,06% versus 20.97% in the control group (cirrhotics without HH). Conclusions: Hepatic hydrothorax is a serious complication of cirrhosis that requires early recognition and proper management, supported by using biomarkers and scoring systems.

Laparoscopic surgery for synchronous double colorectal cancer with obstruction, plus small B cell lymphoma: a case report

Synchronous colorectal cancer is a rare disease. It remains challenging for diagnosis and treatment. This paper reports a case of a 75-year-old Chinese male patient presenting with intestinal obstruction, alongside primary thrombocytopenia and a diagnosis of small B-cell lymphoma. Computed tomography scans revealed space-occupying lesions in both the sigmoid colon and ascending colon. The patient initially underwent a transverse colostomy procedure to alleviate the intestinal obstruction and then underwent laparoscopic radical tumor resection. The patient exhibited favorable prognosis and maintained satisfactory bowel function at the nearly 8 months' postoperative follow-up. Multiple colonoscopies are crucial in the management of synchronous colorectal cancer, and radical surgical resection remains the sole curative option when surgical intervention is deemed tolerable. A thorough preoperative examination and evaluation are crucial for successful surgery. The selection of surgical procedures for synchronous colorectal cancer should be based on the patient's medical condition.

Surgical management of infected emphysema bulla: A case series

INTRODUCTION AND IMPORTANCE

An emphysema bulla is defined as a distension greater than 1 cm of an airspace beyond the terminal bronchioles. Infection of an emphysema bulla is a common and serious complication of chronic obstructive pulmonary disease (COPD), which can lead to significant morbidity. Surgical intervention may be necessary in severe cases to prevent further complications.

CASE PRESENTATION

We present a case series of seven male patients with an average age of 46 years, all diagnosed with infected emphysema bullae. The predominant clinical symptom was chest pain, often accompanied by fever and chills. Chest X-rays revealed hyperclarity occupying more than two-thirds of the pulmonary field in all patients. A follow-up CT scan confirmed the presence of large bullous emphysema. All patients received antibiotics for one to two weeks before surgery.

CLINICAL DISCUSSION

Surgical management was performed in all cases due to the severity of the infection and the size of the bullae. Postoperative recovery was uneventful in four patients. Two patients experienced prolonged air leaks requiring extended chest drainage, and one patient developed atelectasis, which resolved favorably with conservative management. This case series highlights the role of timely surgical intervention in the treatment of infected emphysema bullae and the associated postoperative complications.

CONCLUSION

Infected emphysema bullae represent a significant complication in patients with COPD. Surgical intervention, alongside antibiotic therapy, offers a safe and effective treatment option, resulting in favorable outcomes for most patients. Prompt diagnosis and management are crucial to avoiding severe complications.

Beyond convention: non-compacted myocardium, ventricular tachycardia, and systolic dysfunction in dextrocardia patients: a case series

Background

Noncompaction of the left ventricle (LVNC) is linked to a higher risk of sudden cardiac death and stroke. Its prevalence ranges from 0.014% to 1.3% in the general population, rising to 7.5% in patients with dextrocardia.

Case summary

A male in his late 70s presented with worsening dyspnea and leg swelling, with dextrocardia and frequent extrasystoles. Imaging revealed right-sided pleural effusion, severely reduced ejection fraction, and ventricular and atrial dilatation. He developed sustained monomorphic VT, was treated with amiodarone, had successful coronary stenting, and received an ICD with no further hospital readmissions or ICD events. A second case involved a male in his late 50s who presented with dyspnea. He had dextrocardia with situs inversus, subsegmental pulmonary embolism, and LVNC. He was treated with enoxaparin, medical therapy, and Holter monitoring, which showed mild arrhythmias. He declined ICD placement but remained event-free during the first year of follow-up.

Discussion

LVNC is a rare condition resulting from abnormal myocardial development during embryogenesis, leading to a two-layered myocardial structure. Diagnosis is based on imaging criteria. LVNC is linked to arrhythmias, heart failure, and conduction abnormalities, requiring interventions such as ICD placement, arrhythmia monitoring, and genetic testing. Further research is needed on genetic associations and long-term outcomes in dextrocardia patients.

A protocol for lumbar spine surgery under spinal anesthesia in resource limited countries: illustrative case series

Introduction

Lumbar spine surgery can be performed under either general or spinal anesthesia. Numerous studies highlight the benefits of spinal anesthesia (SA), including cost-effectiveness, reduced anesthesia-related complications, and suitability for patients who do not favor general anesthesia (GA). Those informal case series emphasizes the advantages of SA and introduces a working protocol tailored for resource-limited countries (RLCs).

Presentation of case

Two patients, aged 35 and 58, underwent spinal surgery using SA combined with local infiltration for the skin and facet joints. We implemented a new protocol believed to be beneficial in RLCs. In both cases, intraoperative vital signs remained stable, and there was effective pain control postoperatively.

Clinical discussion

Spine surgery under SA has gained acceptance due to evidence indicating reduced perioperative risks and lower opioid consumption, alongside decreased healthcare costs. Although there are suggested protocols for SA in spine surgery, many are not applicable in RLCs. Our case series demonstrate similar advantages, suggesting that the protocol used in this study may be helpful. Despite its benefits, SA for spine surgery still faces resistance and has not been widely adopted in many neurosurgery centers.

Conclusion

The study aim to outline essential steps for initiating SA for spine surgery in RLCs. The guidelines utilized in this study have proven effective. SA can lead to reduced healthcare costs, lower opioid usage, and increased patient turnover. The two cases series demonstrate improved anesthesia outcomes. Future randomized clinical trials with sufficiently large sample sizes are necessary to establish high-quality evidence regarding the safety, efficacy, and cost-effectiveness of SA.

Psychotic-like experiences and associated factors in resident physicians: A Canadian cross-sectional study

AIM

Medical residency training is associated with a range of sociodemographic, lifestyle and mental health factors that may confer higher risk for psychotic-like experiences (PLEs) in residents, yet little research has examined this question. Thus, we aimed to document the prevalence and associated factors of PLEs among resident physicians.

METHODS

Physicians enrolled in residency programmes in the Province of Québec, Canada (four universities) were recruited in Fall 2022 via their programme coordinators and social media. They completed an online questionnaire assessing PLEs in the past 3 months (the 15-item Community Assessment of Psychic Experiences), as well as sociodemographic characteristics, lifestyle and mental health. Analyses included survey weights and gamma regressions.

RESULTS

The sample included 502 residents (mean age, 27.6 years; 65.9% women). Only 1.3% (95% CI: 0.5%, 4.0%) of residents met the screening cut-off for psychotic disorder. Factors associated with higher scores for PLEs included racialised minority status (relative difference: +7.5%; 95% CI: +2.2%, +13.2%) and English versus French as preferred language (relative difference: +7.9% 95% CI: +3.1%, +12.9%), as well as each additional point on scales of depression (relative difference: +0.8%; 95% CI: +0.3%, +1.3%) and anxiety (relative difference: +1.3%; 95% CI: +0.8%, +1.7%). In secondary analyses, racialised minority status was associated with persecutory items, but not with other PLEs. Gender, residency programmes and lifestyle variables were not associated with PLEs.

CONCLUSIONS

This study found low reports of PLEs in a sample of resident physicians. Associations of PLEs with minoritised status may reflect experiences of discrimination.

A longitudinal study to COVID-19 infection among university students: Physical fitness changes and psychological responses

Background

The impact of COVID-19 infection on physical and mental health of young adults remains unclear. This study aimed to investigate the changes in the physical fitness three months after recovering from acute COVID-19 infection, and examine if the infection could also influence the mental health of university students.

Methods

A total of 460 university students (mean age 18.9 ± 1.3 years, with 30 males and 27 females uninfected with COVID-19) volunteered for the study. Participants underwent a fitness test initially, followed by another physical fitness test and a mental health assessment three months after the infection of COVID-19. Physical fitness tests included body composition, flexibility, cardiorespiratory fitness, muscle strength, and muscular endurance. Mental health was assessed using the Depression-Anxiety-Stress Self-Assessment Scale (DASS-21), the Pittsburgh Sleep Quality Inventory (PSQI), and the Post-Traumatic Stress Disorder Self-Assessment Scale (PTSD).

Results

Three months after acute COVID-19 infection, the physical performance of university students had decreased compared to pre-infection levels by approximate 3-15 % (p < 0.05). Regarding mental health, a notable difference was observed in sleep quality, with the positive group scoring 19 % higher than the negative group (p < .05, d = .44). Sex (β = .164, p < .05), previous infection (β = .277, p = .019) and anxiety (β = .373, p = .002) were predictive of PSQI scores, accounting for 37.5 % of the variance.

Conclusions

All participants experienced a decline in physical fitness compared to their pre-infection levels, regardless of infection status. Those who had been infected exhibited poorer sleep quality compared to their non-infected peers. Prior COVID-19 infection and higher anxiety levels may contribute to poorer sleep quality.

The Importance of Circulation in Airway Management: Preventing Postintubation Hypotension in the Trauma Bay

OBJECTIVE

To identify the modifiable and nonmodifiable risk factors associated with postintubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay.

BACKGROUND

ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain underinvestigated.

METHODS

This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both preintubation and postintubation. Multivariable logistic regression analysis was performed to identify the modifiable and nonmodifiable factors associated with PIH.

RESULTS

Seven hundred eight patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) years and 71% were male. Median [interquartile range] arrival Glasgow Coma Scale was 7 [3-13]. Patients who developed PIH had a lower mean (SD) preintubation systolic blood pressure [118 (46) vs 138 (28), P <0.001] and higher median [interquartile range] Injury Severity Score: 27 [21-38] versus 21 [9-26], P <0.001. Multivariable regression analysis identified body mass index >25, increasing Injury Severity Score, penetrating injury, spinal cord injury, preintubation packed red blood cell requirements, and diabetes mellitus as nonmodifiable risk factors associated with increased odds of PIH. In contrast, preintubation administration of 3% hypertonic saline and vasopressors were identified as the modifiable factors significantly associated with reduced PIH.

CONCLUSIONS

More than half of the patients requiring ETI in the trauma bay developed PIH. This study identified modifiable and nonmodifiable risk factors that influence the development of PIH, which will help physicians when considering ETI upon patient arrival.

LEVEL OF EVIDENCE

Level III-Prognostic study.

Spontaneous splenic rupture: A rare complication of concurrent malaria and dengue infections - A case report

INTRODUCTION

Spontaneous splenic rupture (SSR) is a rare, life-threatening complication, sometimes associated with infections like malaria and dengue fever. This case report details a unique presentation of SSR.

CASE PRESENTATION

A 28-year-old male in Somalia presented with fever, epigastric pain, nausea, vomiting, and body aches, consistent with malaria and dengue. Following self-discharge after initial malaria treatment, his condition deteriorated rapidly, leading to severe abdominal pain and hypotension. Laboratory tests confirmed malaria and dengue, with low hemoglobin. A CT scan revealed a large hemoperitoneum and splenic rupture requiring emergency laparotomy and splenectomy. Post-operative recovery was uneventful.

DISCUSSION

This case highlights the diagnostic challenges posed by overlapping symptoms of malaria and dengue, potentially masking SSR. The concurrent infections likely contributed to splenomegaly, increasing rupture risk. While SSR has been linked to malaria or dengue individually, this case suggests a potential synergistic effect of co-infection. The patient's self-discharge emphasizes the importance of patient education and treatment adherence. Successful surgical intervention underscores the critical role of prompt medical care.

CONCLUSION

This is the first reported case of SSR secondary to concurrent Plasmodium falciparum malaria and dengue fever in Somalia. This highlights the need for improved diagnostic tools, healthcare infrastructure, and targeted public health interventions in endemic regions. Further research is crucial to understand the synergistic effect of these co-infections in inducing SSR.

Role of HIF-1α in the Responses of Tumors to Radiotherapy and Chemotherapy

Tumor microenvironment is intrinsically hypoxic with abundant hypoxia-inducible factors-1α (HIF-1α), a primary regulator of the cellular response to hypoxia and various stresses imposed on the tumor cells. HIF-1α increases radioresistance and chemoresistance by reducing DNA damage, increasing repair of DNA damage, enhancing glycolysis that increases antioxidant capacity of tumors cells, and promoting angiogenesis. In addition, HIF-1α markedly enhances drug efflux, leading to multidrug resistance. Radiotherapy and certain chemotherapy drugs evoke profound anti-tumor immunity by inducing immunologic cell death that release tumor-associated antigens together with numerous pro-immunological factors, leading to priming of cytotoxic CD8+ T cells and enhancing the cytotoxicity of macrophages and natural killer cells. Radiotherapy and chemotherapy of tumors significantly increase HIF-1α activity in tumor cells. Unfortunately, HIF-1α effectively promotes various immune suppressive pathways including secretion of immune suppressive cytokines, activation of myeloid-derived suppressor cells, activation of regulatory T cells, inhibition of T cells priming and activity, and upregulation of immune checkpoints. Consequently, the anti-tumor immunity elevated by radiotherapy and chemotherapy is counterbalanced or masked by the potent immune suppression promoted by HIF-1α. Effective inhibition of HIF-1α may significantly increase the efficacy of radiotherapy and chemotherapy by increasing radiosensitivity and chemosensitivity of tumor cells and also by upregulating anti-tumor immunity.

Severe Acute Pancreatitis Complicated by Multiple Intra-Abdominal Hemorrhages

Introduction

Intra-abdominal hemorrhage is a rare yet life-threatening complication of acute pancreatitis (AP), with a higher prevalence in cases of severe acute pancreatitis (SAP). This condition is primarily caused by vessel wall erosion and rupture of pseudoaneurysms (PSAs). However, SAP cases involving multiple sequential arterial hemorrhages are extremely rare. This condition is primarily brought on by the process of vessel wall degeneration and the development of PSAs. Nonetheless, SAP necessitating multiple episodes of arterial bleeding is very uncommon.

Case Presentation

Here is the case history of a 31-year-old man already being treated for SAP. His condition was then complicated by massive, frequent intra-abdominal bleeding. The patient initially presented to the hospital with SAP. He was transferred to the intensive care unit for proper management. Massive intra-abdominal bleeds occurred on the 31st, 45th, and 60th days during hospitalization. The maximum blood loss was 1,500 mL. In each of the instances, digital subtraction angiography (DSA) embolization was carried out after the bleeding source had been verified. In order to manage SAP, continuous percutaneous drainage and staged pancreatic necrosectomy were undertaken for 6 months. No recurrence of intra-abdominal hemorrhage was detected. Infection of the abdominal cavity was properly controlled. The patient left the hospital in good condition.

Conclusion

Spontaneous bleeding in the abdominal cavity is a severe and life-threatening complication of SAP. This is often caused by vessel wall erosion. In such cases, DSA plays a crucial role in diagnosis and management. Besides precisely locating the bleeding source, one can perform a much-needed embolization immediately. Consequently, the disease is under total control, and the patient is much more likely to survive.

Lessons Learned From Clinical Trials of Immunotherapeutics for COVID-19

The COVID-19 pandemic caused by the SARS-CoV-2 virus was arguably one of the worst public health disasters of the last 100 years. As many infectious disease experts were focused on influenza, MERS, ZIKA, or Ebola as potential pandemic-causing agents, SARS-CoV-2 appeared to come from nowhere and spread rapidly. As with any zoonotic agent, the initial pathogen was able to transmit to a new host (humans), but it was poorly adapted to the immune environment of the new host and resulted in a maladapted immune response. As the host-pathogen interaction evolved, subsequent variants of SARS-CoV-2 became less pathogenic and acquired immunity in the host provided protection, at least partial protection, to new variants. As the host-pathogen interaction has changed since the beginning of the pandemic, it is possible the clinical results discussed here may not be applicable today as they were at the start of the pandemic. With this caveat in mind, we present an overview of the immune response of severe COVID-19 from a clinical research perspective and examine clinical trials utilizing immunomodulating agents to further elucidate the importance of hyperinflammation as a factor contributing to severe COVID-19 disease.

Application of Artificial Intelligence in Prediction of Ki-67 Index in Meningiomas: A Systematic Review and Meta-Analysis

BACKGROUND

The Ki-67 index is a histopathological marker that has been reported to be a crucial factor in the biological behavior and prognosis of meningiomas. Several studies have developed artificial intelligence (AI) models to predict the Ki-67 based on radiomics. In this study, we aimed to perform a systematic review and meta-analysis of AI models that predicted the Ki-67 index in meningioma.

METHODS

Literature records were retrieved on April 27, 2024, using the relevant key terms without filters in PubMed, Embase, Scopus, and Web of Science. Records were screened according to the eligibility criteria, and the data from included studies were extracted. The quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The meta-analysis, sensitivity analysis, and meta-regression were conducted using R software.

RESULTS

Our study included 6 studies. The mean Ki-67 ranged from 2.7 ± 2.97 to 4.8 ± 40.3. Of 6 studies, 5 utilized a machine learning method. The most used AI method was the least absolute shrinkage and selection operator. The area under the curve and accuracy ranged from 0.83 to 0.99 and 0.81 to 0.95, respectively. AI models demonstrated a pooled sensitivity of 87.5% (95% confidence interval [CI]: 75.2%, 94.2%), a specificity of 86.9% (95% CI: 75.8%, 93.4%), and a diagnostic odds ratio of 40.02 (95% CI: 13.5, 156.4). The summary receiver operating characteristic curve indicated an area under the curve of 0.931 for the prediction of Ki-67 index status in intracranial meningiomas.

CONCLUSIONS

AI models have demonstrated promising performance for predicting the Ki-67 index in meningiomas and can optimize the treatment strategy.

Mapping the scientific landscape and evolution of the International Journal of Surgery : a scientometric analysis (2004-2024)

AIM

The purpose of this study was to analyze the publication characteristics and development of the International Journal of Surgery (IJS) over its 20-year history.

METHODS

This study included articles published in IJS during the 20 years from 2004 to 2024. The data were analyzed using the Citespace, VOS viewer, and the 'Bibliometrix' package in R software. The authors studied the dynamics and trend patterns of IJS literature production through descriptive bibliometrics and identified the most prolific authors, publications, institutions, and countries. Bibliometric maps were utilized to visualize published articles' content and identify the most prolific research terms and topics in IJS , as well as their evolution over time.

RESULTS

A total of 5964 publications in the IJS from 2004 to 2023 and 356 publications in 2024 were included in the analysis. The study revealed a positive trend in literature production, although the number of articles published in IJS has slightly decreased recently. The most productive country was China ( n =1211), the most productive institution was Sichuan University ( n =151), and the most prolific author was Wang Yang ( n =87). The top 15 most cited articles focus primarily on research reporting standard guidelines for surgical studies. Research published in IJS mainly targeted middle-aged and older adults, emphasizing postoperative complications and treatment outcomes. The future research focus in IJS might center on integrating artificial intelligence and deep learning technologies to revolutionize surgical research and practice.

CONCLUSIONS

The International Journal of Surgery significantly contributes to advances in surgical research. IJS prioritized enhancing patient outcomes and advancing surgical techniques, focusing on middle-aged and older adults, postoperative complications, and treatment outcomes. The journal emphasized robust evidence through retrospective, controlled, and cohort surgical studies. Integrating artificial intelligence and deep learning represented a significant frontier poised to revolutionize surgical care, shaping the future landscape of research and practice.

Untangling Breast Cancer: Trailing Towards Nanoformulations-based Drug Development

All over the world, cancer death and prevalence are increasing. Breast cancer (BC) is the major cause of cancer mortality (15%) which makes it the most common cancer in women. BC is defined as the furious progression and quick division of breast cells. Novel nanotechnology-based approaches helped in improving survival rate, metastatic BC is still facing obstacles to treat with an expected overall 23% survival rate. This paper represents epidemiology, classification (non-invasive, invasive and metastatic), risk factors (genetic and non-genetic) and treatment challenges of breast cancer in brief. This review paper focus on the importance of nanotechnology-based nanoformulations for treatment of BC. This review aims to deliver elementary insight and understanding of the novel nanoformulations in BC treatment and to explain to the readers for enduring designing novel nanomedicine. Later, we elaborate on several types of nanoformulations used in tumor therapeutics such as liposomes, dendrimers, polymeric nanomaterials and many others. Potential research opportunities for clinical application and current challenges related to nanoformulations utility for the treatment of BC are also highlighted in this review. The role of artificial intelligence is elaborated in detail. We also confer the existing challenges and perspectives of nanoformulations in effective tumor management, with emphasis on the various patented nanoformulations approved or progression of clinical trials retrieved from various search engines.

Management challenges of ovarian adult-type granulosa cell tumors at a tertiary facility in resource-limited setting: A case series of three patients and review of the current literature

INTRODUCTION AND IMPORTANCE

Adult-type granulosa cell tumors (AGCTs) are rare, low-grade malignant ovarian sex-cord stromal tumors, accounting for approximately 5 % of all ovarian tumors. These tumors are characterized by their potential for late recurrence and complex management, which presents significant challenges, particularly in resource-limited settings where access to advanced diagnostic tools and treatment options is restricted. This study highlights a series of rare AGCT cases diagnosed in premenopausal and postmenopausal women in Northern Tanzania. Given the global rarity of AGCTs and the limited literature on the condition, especially in this region, this study aims to address a critical knowledge gap.

CASE SERIES

This report presents a series of three patients diagnosed with ovarian adult-type granulosa cell tumors (AGCTs) based on histological findings. The series underscores the variability in clinical presentations and highlights the significance of individualized treatment approaches in managing these rare tumors.

CLINICAL DISCUSSION

Managing AGCTs in resource-limited settings requires balancing optimal care with available resources. Surgery remains the cornerstone of treatment; however, the lack of advanced diagnostic tools and limited access to adjuvant therapies necessitate a focus on achieving the best possible surgical outcomes and prioritizing rigorous clinical follow-up. This report explores the rarity of AGCTs, reviews existing literature on similar cases, and examines the numerous challenges associated with their management in such settings.

CONCLUSION

Adult granulosa cell tumors are rare, low-grade malignant neoplasms of the ovarian sex-cord stromal origin. These tumors are notable for their potential to recur even years after initial treatment. Consequently, regular follow-up with clinical examinations and tumor marker assessments is recommended. While chemotherapy can provide palliative benefits and manage recurrence, surgery remains the cornerstone of treatment, as illustrated in our case report.

In silico and in vivo experiments of Huperzine A modulating the development of obstructive sleep apnea by transcriptionally regulating pyruvate carboxylase expression via retinoid X receptor alpha

IntroductionThis study investigated the molecular mechanism by which HuA influences the expression of pyruvate carboxylase via retinoid X receptor alpha (RXRA), thereby affecting the progression of obstructive sleep apnea (OSA).MethodsBioinformatics analysis including screening of differentially expressed genes (DEGs) and searching the downstream target genes of RXRA were conducted. Cognitive function, neuronal damage, oxidative stress, and inflammation were evaluated in chronic intermittent hypoxia (CIH) mouse models. The Morris water maze test was used to assess swimming path length, escape latency, and platform crossing times. H&E and Nissl staining was performed to evaluate pathological changes and neuronal counts in brain tissue. ELISA was utilized to measure the oxidative stress levels and inflammatory cytokines. RXRA enrichment in the pyruvate carboxylase promoter region in CIH was assessed using Chromatin Immunoprecipitation (ChIP), and the effect of RXRA on pyruvate carboxylase promoter activity was analyzed using dual-luciferase assay.ResultsRXRA was identified as a potential regulatory target gene of HuA. Pyruvate carboxylase was identified as a RXRA target gene and a significant DEG in OSA. CIH-induced cognitive impairment, neuronal damage, oxidative stress, and inflammation in mice, while such symptoms were alleviated by HuA treatment. In OSA, suppression of RXRA expression led to reduced pyruvate carboxylase expression. HuA treatment enhanced RXRA expression, thereby promoting pyruvate carboxylase expression. HuA alleviated CIH-induced cognitive impairment, neuronal damage, oxidative stress, and inflammation via the RXRA/pyruvate carboxylase axis.ConclusionIn summary, HuA alleviates CIH-induced cognitive impairment, neuronal damage, oxidative stress, and inflammation by promoting the RXRA/pyruvate carboxylase axis.

IgG4-related retroperitoneal fibrosis presenting as a peripancreatic mass: a case series

Introduction

IgG4-related disease (IgG4-RD) is a chronic, immune-mediated disorder characterized by widespread inflammation and fibrosis, leading to potential organ dysfunction if untreated. Often underdiagnosed due to subtle and varied symptoms, the disease can affect multiple organ systems. This case series highlights two patients who were diagnosed as cases of IgG4-related retroperitoneal fibrosis.

Methods

A total of two patients were included in this prospective case series who presented to the gastroenterology department of a tertiary care hospital with the same signs and symptoms and were diagnosed with IgG4-related retroperitoneal fibrosis (IgG4-RPF).

Case summary

Two patients were included in our case series, aged 25 and 26 years. The chief complaints included dull, radiating epigastric pain, other symptoms include diffuse abdominal pain, intensified, accompanied by nausea, vomiting, and episodic diarrhea, and a history of B-cell lymphoproliferative disorder. Endoscopic ultrasound (EUS)-)-guided biopsies were performed, showing findings consistent with (IgG4-RPF). Both patients were started on a regimen of prednisolone, pantoprazole, and vitamin D, which they tolerated well without adverse effects. They were advised to follow up with a CT scan after one month.

Conclusion

IgG4-related disease (IgG4-RD) is a rare, chronic condition often presenting as retroperitoneal fibrosis (RPF) and affecting multiple organs. Serum IgG4 levels can be normal in certain cases, histopathological and radiological investigations are necessary for the correct diagnosis. Early initiation of immunosuppressive drugs are necessary for the disease control.

Exploring β-caryophyllene: a non-psychotropic cannabinoid's potential in mitigating cognitive impairment induced by sleep deprivation

Sleep deprivation or sleep loss, a prevalent issue in modern society, is linked to cognitive impairment, leading to heightened risks of errors and accidents. Chronic sleep deprivation affects various cognitive functions, including memory, attention, and decision-making, and is associated with an increased risk of neurodegenerative diseases, cardiovascular issues, and metabolic disorders. This review examines the potential of β-caryophyllene, a dietary non-psychotropic cannabinoid, and FDA-approved flavoring agent, as a therapeutic solution for sleep loss-induced cognitive impairment. It highlights β-caryophyllene's ability to mitigate key contributors to sleep loss-induced cognitive impairment, such as inflammation, oxidative stress, neuronal death, and reduced neuroplasticity, by modulating various signaling pathways, including TLR4/NF-κB/NLRP3, MAPK, Nrf2/HO-1, PI3K/Akt, and cAMP/PKA/CREB. As a naturally occurring, non-psychotropic compound with low toxicity, β-caryophyllene emerges as a promising candidate for further investigation. The review underscores the therapeutic potential of β-caryophyllene for sleep loss-induced cognitive impairment and provides mechanistic insights into its action on crucial pathways, suggesting that β-caryophyllene could be a valuable addition to strategies aimed at combating cognitive impairment and other health issues due to sleep loss.

Personalized Rehabilitation of Atrophic Customized Subperiosteal Implants

Severe maxillary atrophy and edentulism can pose a range of challenges in implant planning and oral rehabilitation. Modern dentistry has allowed for a review of the concepts and surgical protocols of subperiosteal implants, presenting them as a solution for the rehabilitation of atrophic maxillary and mandibular bone deficiencies. This study aims to address a series of 3 patients with severe maxillary atrophy, as evidenced by presurgical and postsurgical radiographic images, as well as computer-assisted planning and analysis of patient anatomy for rehabilitation with custom sintered subperiosteal implants. Promising results these clinical cases, highlighting the precise technique, biocompatibility, and durability of these materials. The absence of postoperative complications was evident, with high success rates in procedures and patient reports. Importantly, periodic follow-up is needed to assess the longevity and effectiveness of the technique used.

Phylogenetic Characterization of Vibrio vulnificus Strains from Oysters and its Comparison with Clinical vcgE Genotype Strain

Twenty-one environmental Vibrio vulnificus strains from the Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE) bacteria collection, 20 of them isolated from oyster samples and 1 from a reported clinical case, were sequenced to analyze the genomic divergence between 2 genotypes, E-genotype and C-genotype, proposed by various groups to distinguish clinical (C) from environmental (E) V. vulnificus strains. As indicated in previous analyses of PFGE, MLST, and rtxA, 9 of the CICESE isolates were identified as vcgE, compared with 12 as vcgC. Separation of the genotypes into these 2 groups was confirmed in this study, based on the presence of certain genes in the 21 genomes, the presence of virulence factors, and rtxA sequencing. Most genomes from oyster isolates expressed rtxA-C type, with the exception being rtxA-M type detected in CICESE-594 a vcgE strain isolated from a clinical case. Although several genetic approaches clearly indicate differences between the C- and E-genotypes, none of them, including those in this study, can highlight a single factor that could be used to indicate the potential pathogenicity of V. vulnificus isolated from oysters.

The Impact of Living in a Low Food Access/Low Income Area on Obstructive Sleep Apnea

OBJECTIVE

To assess differences in obstructive sleep apnea (OSA)-related health parameters between residents of low income/low access (LILA) census tracts-food deserts-and non-LILA residents STUDY DESIGN: Retrospective review.

SETTING

Single institution serving a large region in Southern California from 2017 to 2023.

METHODS

Census tracts are defined as LILA if a significant proportion of residents live below the poverty threshold and far from healthy food vendors. Adults newly diagnosed with OSA on polysomnography were included. Food access status was determined by searching patient addresses in the US Department of Agriculture Food Access Research Atlas. Baseline and 1-year follow-up body mass index (BMI) and vitals were collected and compared based on food access and other demographic variables.

RESULTS

A total of 379 patients in the LILA+ group and 2281 patients in the LILA- group met inclusion criteria. BMI was higher in the LILA group (36.6 ± 9.4 vs 35.2 ± 8.9; P = .006). The effect of food access was most significant in certain demographic groups: patients aged < 65, males, Asian/Pacific Islanders, Hispanics, and patients with Medicaid coverage all had a higher BMI when in the LILA+ group compared to the LILA- group. When considering insurance, LILA+ patients with Medicaid coverage had a significantly higher BMI than LILA- patients with non-Medicaid coverage (40.4 ± 10.3 vs 34.2 ± 8.4, P < .001. Blood pressure, heart rate, and apnea-hypopnea index were also significantly higher in LILA+/Medicaid group. BMI change across all demographic groups was minimal at 1-year follow-up.

CONCLUSION

Living in a LILA census tract may result in worse OSA-related health parameters. When accounting for insurance status, the effects are even more profound. Intensive counseling on the importance of weight management should begin at the diagnosis of OSA.

Complete traumatic urethral cut and vesicovaginal fistula in a 3-year-old girl, managed by Mitrofanoff procedure: a case report

We report a 3-year-old patient with urethral cut injury and iatrogenic vesicovaginal fistula following a pelvic fracture; managed with Mitrofanoff procedure. Our patient presented with straining on urination with continuous colorless discharge on her diaper for the past 4 months. Investigations identified vesicovaginal fistulization making a definitive diagnosis of complete urethral injury. It was managed with the Mitrofanoff procedure to preserve the patient's urinary continence. Our case is to our knowledge the youngest reported case of a complete traumatic urethral cut in a female; an already rare encounter in this population. This is also the first such case to be managed via the Mitrofanoff procedure. Although the management was delayed, it was successful.

Stone-free rate of laser lithotripsy for large pediatric stones: 15-year experience from a tertiary endourology pediatric center

Background

Pediatric urolithiasis, while less common than in adults, is increasing in incidence. However, current guidelines on the optimal management of this condition vary. Technological advances have led to improvements in the quality and size of ureteroscopes, thus enabling their use in children. Despite this, there remains some hesitancy about using ureteroscopic lithotripsy in the pediatric population, particularly in cases of large stones ⩾10 mm.

Objectives

In this study, our aim was to evaluate the efficacy and safety of ureteroscopy and laser stone fragmentation (URSL) for managing pediatric patients with a cumulative stone burden of ⩾10 mm in our tertiary referral center.

Methods

A dataset was collected of pediatric renal tract stone patients treated at a single tertiary urological center between June 2010 and May 2024 (15 years). Pediatric patients undergoing URSL procedures for a minimum cumulative stone burden ⩾10 mm were included. A retrospective analysis of the dataset was conducted. The primary outcomes measured were stone-free rates (SFR), complications classified according to the Clavien-Dindo classification, and hospital length of stay.

Results

A total of 61 pediatric patients with a mean age of 10 years (range: 2.3-16) underwent 83 URSL procedures in a tertiary endourology pediatric center over a 15-year period (2010-2024). The median initial stone burden was 17 mm (IQR: 12.5-24 mm), acquired from preoperative ultrasonography (USS). Results showed a first-pass SFR of 63.9% and a cumulative SFR of 93.4% (on USS) following one or multiple URSL procedures (1.4 procedures/patient). Immediate postoperative complications were minimal, with 6% experiencing complications classified as Clavien-Dindo I or II. The average hospital length of stay was 1.4 days.

Conclusion

The findings in this study support that URSL is effective in treating pediatric urolithiasis, even for larger stone burdens. Further research is needed to standardize guidelines and optimize management strategies in this population.

Primary Tracheal Schwannoma With Extension to the Thyroid Gland: Management

The occurrence of neurogenic tumors in the tracheobronchial tree is uncommon. We report a case of transmural tracheal schwannoma with extraluminal component extending upto the left thyroid lobe. 40-year-old male presented with scanty hemoptysis due to transmural tracheal schwannoma with extraluminal part of tumor extending till the left lobe of thyroid gland. Patient underwent tracheal resection and anastomosis with en-bloc excision of left thyroid lobe due to the nature and size of the tumor. Tracheal Schwannoma are not that frequent. Symptoms can misguide the clinician causing delay in diagnosis from the onset of symptoms. Definitive diagnosis is made after histopathological examination and immunohistochemical studies. So far, resection and anastomosis of trachea has been adequate treatment. Tracheal neoplasms are unusual and tracheal schwannomas are very unique. The case highlights the varied presentation of tracheal schwannoma and confusion faced to diagnose the patient and provide an optimal management.

Refractory Gastric Outlet Obstruction Due to a Duodenal Stricture in the Setting of a Cholecystoduodenal Fistula

Gastric outlet obstruction (GOO) is a clinical condition in which an underlying disease process leads to a lack of gastric emptying. The presentation and management of GOO due to a variety of benign and malignant causes have been researched; however, limited medical literature exists on the presentation and management of refractory GOO caused by a duodenal stricture secondary to a cholecystoduodenal fistula. This case report highlights the diagnostic challenges and the significance of timely intervention. This case of a 66-year-old female with GOO refractory to multiple endoscopic interventions demonstrates the presentation and management of such a rare cause of GOO and highlights the importance of surgical consultation in persistent GOO. The etiology of GOO varies widely, requiring a range of treatments from medical management to surgery. This case underscores the importance of identifying the cause to ensure effective treatment. Cholecystoduodenal fistulas are rare but significant, often necessitating surgical intervention when endoscopic procedures fail. Our patient had a duodenal stricture due to a cholecystoduodenal fistula, indicating the necessity for surgical consultation.

The Use of Front Plateau in the Treatment of Temporomandibular Disorders: A Case Series and Literature Review

Temporomandibular disorders (TMDs) are conditions with multifactorial etiology and complex treatment. Among the non-invasive therapeutic possibilities for these conditions is the Front Plateau, a partial anterior plate made from colourless self-curing acrylic resin. It is a simple procedure that can be carried out in a single clinical section promoting muscle relaxation to reduce symptoms associated with TMDs. This study aims to report a prospective, consecutive, single-centric case series to evaluate the Front Plateau's effectiveness in patients with temporomandibular disorders. A questionnaire adapted from the Research Diagnostic Criteria for TMDs was used and 4 patients were treated with the Front Plateau plaque. Patients were monitored after 5 and 9 months, respectively, after starting to use the Front Plateau. Of the 4 cases listed, 2 showed significant improvement in initial signs and symptoms. Front Plateau may be a favourable treatment option for patients with TMD, if the guidelines are followed. Clinical trials on this modality should seek to minimize possible biases and limitations associated with the design of this type of research.

Twenty-first century mouse genetics is again at an inflection point

The laboratory mouse has been the premier model organism for biomedical research owing to the availability of multiple well-characterized inbred strains, its mammalian physiology and its homozygous genome, and because experiments can be performed under conditions that control environmental variables. Moreover, its genome can be genetically modified to assess the impact of allelic variation on phenotype. Mouse models have been used to discover or test many therapies that are commonly used today. Mouse genetic discoveries are often made using genome-wide association study methods that compare allelic differences in panels of inbred mouse strains with their phenotypic responses. Here we examine changes in the methods used to analyze mouse genetic models of biomedical traits during the twenty-first century. To do this, we first examine where mouse genetics was before the first inflection point, which was just before the revolution in genome sequencing that occurred 20 years ago, and then describe the factors that have accelerated the pace of mouse genetic discovery. We focus on mouse genetic studies that have generated findings that either were translated to humans or could impact clinical medicine or drug development. We next explore how advances in computational capabilities and in DNA sequencing methodology during the past 20 years could enhance the ability of mouse genetics to produce solutions for twenty-first century public-health problems.

Management of Sprengel deformity by modified Woodward approach and outcome: a case series and literature review

Introduction

Sprengel deformity (SD) is a rare congenital deformity consisting of elevation of the scapula, leading to limited range of motion and a visible lump in severe cases. Klippel-Feil syndrome is a rare congenital abnormality characterized by the triad of cervical synostosis, low posterior hairline, and short neck. It is often associated with SD.

Case presentation

We present two cases of SD of a 7-year-old boy and a 10-year-old boy. They were both born with the abnormality and complained of limited range of motion in the affected shoulder.

Clinical discussion

Patients with less severe forms of SD can lead a normal life with supportive treatment, and it is not connected with cognitive impairment; however, there may be a limited range of motion and cosmetic concerns. In severe cases, treatment entails operative therapy with corrective placement of the scapula and resection of the omovertebral band.

Conclusion

Patients with SD require supportive physiotherapy from a young age. Severe cases need operative treatment at a young age. The modified Woodward approach may be an excellent surgical option to correct the deformity.

Intraoperative indocyanine green with ultrasound-guided localization as prodigious adjuncts explicating negative margin in functional insulinoma: A case report

INTRODUCTION AND IMPORTANCE

Insulinomas are rare pancreatic neuroendocrine neoplasms with an incidence of one to four cases per million annually and a 5 % to 10 % association with hereditary multiple endocrine neoplasia type-1. While most insulinomas are benign and well-encapsulated, approximately 6 % may have malignant potential. Intraoperative localization remains a vital component of treatment, often facilitated by modern imaging techniques like intraoperative ultrasound and fluorescence modalities.

CASE PRESENTATION

A 52-year-old woman was referred to Kathmandu Medical College with generalized weakness, recurrent headaches, and fatigue relieved by food intake. She had a history of hypoglycemia-induced abnormal body movements and loss of consciousness. After biochemical and imaging evaluations, she was diagnosed with pancreatic insulinoma. Based on the higher affinity of neuroendocrine tumoral cells for Indocyanine Green compared to normal pancreatic cells, the patient underwent Indocyanine Green-directed laparoscopic-assisted pancreaticoduodenectomy managed perioperatively with subcutaneous octreotide. She had an uneventful postoperative period and was discharged on the eighth day.

DISCUSSION

Insulinomas present a unique diagnostic and therapeutic challenge, especially in cases of sporadic occurrence. Surgical resection is the mainstay of treatment, with enucleation preferred for benign tumors. In this case, fluorescence-guided surgery and intraoperative ultrasound aided in accurate localization and successful excision.

CONCLUSION

Insulinomas, though rare, require prompt diagnosis and surgical intervention to prevent malignancy and metastasis.

Laminoplasty and In-Site Regrafting for the Treatment of Thoracic Ossification of the Ligamentum Flavum: A Surgical Technique

OBJECTIVE

Current surgical strategies for thoracic ossification of the ligamentum flavum (TOLF) are denounced by thoracic kyphosis, loss of spinal motion range, etc. A new surgical technique, laminoplasty and in-site regrafting (LPIR), was modified to address the problems. This study aimed to report the safety and feasibility of LPIR for TOLF treatment.

METHODS

This retrospective study reported the outcome of eight consecutive patients (3 males and 5 females, mean age 52.87 years) with TOLF who underwent LPIR surgery from January 2019 to March 2024. Pre- and post-operative data including x-ray, computerized tomography (CT), magnetic resonance imaging (MRI), the modified Japanese Orthopedic Association score (mJOA), the visual analog scale (VAS), and complications were collected to evaluate the outcome.

RESULTS

All surgeries were performed successfully, significantly alleviating symptoms postoperatively. During an average follow-up period of 28.63 months, the VAS score reduced from 4.50 ± 1.00 pre-operatively to 1.63 ± 0.48 on the third post-operative day and further reduced to 0.50 ± 0.70 during the last follow-up. The mJOA score increased from 3.63 ± 0.70 pre-operatively to 6.13 ± 0.78 on the third postoperative day and further increased to 8.88 ± 1.27 during the last follow-up. No severe complications were observed.

CONCLUSIONS

LPIR exhibited significant safety and feasibility for treating TOLF, offering a novel strategy for managing this problem.

Feasibility and Safety of Bridging Antiplatelet Therapy with Cangrelor in Neuro-Oncology: A Preliminary Experience

Antiplatelet therapy is mandatory for prevention of thrombotic events in patients with a recent history of acute coronary syndromes and/or percutaneous coronary interventions. However, if an urgent surgery is required during antiplatelet therapy, a compromise between the ischemic/thrombotic and hemorrhagic risk has to be reached. Different bridging schemes are reported in the literature, but there is no clear consensus on the optimal treatment strategy in terms of efficacy and safety. Although some indications about the perioperative management of antiplatelet therapy regarding specific surgical specializations are available, balancing the thrombotic and hemorrhagic risk on an individual basis, no evidence referring to neurosurgical or neuro-oncologic procedures is reported. Herein, we present our preliminary experience in the perioperative management of a patient who underwent a neurosurgical procedure for the resection of a primary malignant brain tumor using an intravenous P2Y12 inhibitor (cangrelor) as bridging therapy after a recent acute myocardial infarction treated with primary percutaneous coronary intervention and stenting. The oral P2Y12 inhibitor (clopidogrel) was withdrawn 5 days prior to the surgical procedure and continuous infusion of cangrelor was started 3 days before the surgery at a dose of 0.75 μg/kg/min. Cangrelor was discontinued 2 hours before surgery and resumed 72 hours after tumor resection for further 60 hours. Neither cangrelor-related bleeding nor cardiac ischemic events were observed in the perioperative period and the following 90 days, supporting data regarding the feasibility and safety of this bridging scheme. Further studies are needed to confirm our promising results.

Histopathological analysis of gamma sarcoglycanopathy in Moroccan patients: A case series

INTRODUCTION AND IMPORTANCE

In Morocco, diagnosing Gamma Sarcoglycanopathies mainly relies on histopathological analysis of muscle biopsies due to limited genetic and molecular research access. This study highlights the significance of muscle biopsies and explores potential predictive factors and possible correlation between histopathological abnormalities and clinical phenotypes.

CASE PRESENTATION

Muscle biopsies of six patients diagnosed with γ-sarcoglycanopathy were collected over two years. Pathological analysis was initially performed on slides stained with Hematoxylin-Eosin and Gomori Trichrome. Additionally, cryosections marked for dystrophin, alpha, beta, and gamma sarcoglycans were reviewed. In the second phase of the analysis, formalin-fixed sections from each biopsy were immunostained for various markers: "anti-CD68" for macrophagic cells, "anti-CD56" for satellite cells, and "anti-CD31" for vascular capillary. These stained sections were then carefully examined.

CLINICAL DISCUSSION

The clinical presentation of the disease was uniform and consistent with Duchenne-like dystrophy. However, the histological abnormalities were heterogeneous and did not correlate with the severity of the clinical phenotype. The Loss of expression of a Sarcoglycan and earlier age of onset appear to be the most significant predictive markers of disease progression. Immuno-staining patterns for CD68, CD56, and CD31 indicated an impairment in the muscle regeneration process, probably, at an early stage of the disease.

CONCLUSION

This study's findings are crucial for understanding pathogenesis and identifying new therapeutic targets. However, because of the small sample size, further confirmation through a larger cohort is necessary.

Open Surgical Repair in a Patient With Loeys-Dietz Syndrome and Extensive Vascular Compromise: A Case Report and Literature Review

Loeys-Dietz syndrome (LDS) has been associated with multiple vascular abnormalities involving the entire arterial tree. However, limited reports regarding compromise in the aortoiliac and femoral bifurcation are available. Further, recommendations for optimal approach, thresholds for diameter at the time of surgery, and surveillance are also limited. We present a case of a 67-year-old male patient with LDS and aneurysmal aortoiliac and enlarging common femoral arteries aneurysms, who underwent open surgical repair. His past surgical history included multiple vascular interventions for lower extremity claudication and bilateral hip replacements. The right hip arthroplasty was previously removed due to infection. From the vascular standpoint, the patient underwent staged endovascular left hypogastric artery embolization and open aorto-bi-profunda bypass with a Rifampin-soaked Dacron graft. At 5-month follow-up, he remains asymptomatic with healed incisions and patent bypasses. This case highlights the challenges in managing peripheral aneurysms in LDS patients, emphasizing the need for tailored treatment strategies. While open repair is preferred, endovascular options may be considered in selected cases. Surveillance remains critical with annual cross-sectional imaging. Surgical planning is intricate due to comorbidities, anatomical complexities, and previous surgical infection. Surveillance of these patients must be strict as multiple vascular and non-vascular complications may arise. Therefore, collaborative decision-making is essential for optimal outcomes in this known high-risk population with connective tissue disorders.

Comprehensive guidelines for prehabilitation in spine surgery

Study Design

Literature review.

Objectives

Review prehabilitation techniques used for elective spine surgery to create a comprehensive list of recommendations.

Methods

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines by searching three electronic databases from 1997 to 2021. Pertinent literature reporting information on prehabilitation, applicable to spine surgery, was identified. Seventy studies were selected for further analysis. Findings from the literature were reinforced by practices employed by the authors.

Results

Preoperative smoking cessation should be achieved 3-4 weeks before elective spine surgery. Preoperative weight loss programs to reach a goal BMI <35 kg/m2 may be a viable solution to minimize wound complications and surgical site infections. To minimize the negative impact of cardiopulmonary comorbidities, patients can enroll in an exercise program prior to surgery. Patients should abstain from alcohol before elective spine surgery. Patients with osteoporosis may benefit from supplementation with Vitamin D, calcium, and parathyroid hormone. Opioids should be weaned to complete cessation 6-8 weeks before surgery. Preoperative cognitive behavioral therapy (CBT) and education seem to be the most beneficial in reducing complications associated with psychiatric comorbidities. Patients should engage in a comprehensive prehabilitation regimen.

Conclusion

Targeting patient risk factors with personalized interventions can improve postoperative outcomes in patients undergoing elective spine surgery.

Nurses' Sleep Quality and Its Influencing Factors During the First Explosive COVID-19 Outbreak in Zhejiang, China, After the Relaxation of Epidemic Prevention and Control Measures: A Multicentre Cross-Sectional Study

AIM

To investigate the sleep quality and its influencing factors among nurses in hospitals in Zhejiang, China, during the first explosive COVID-19 outbreak following the relaxation of prevention and control measures.

DESIGN

A multicentre cross-sectional study.

METHODS

Between 10 January and 20 January 2023-approximately 1 month after the policy was loosened-a total of 573 nurses from tertiary and community hospitals in Zhejiang participated in an online, self-administered survey. The participants were recruited using convenience sampling, and the survey was distributed via the WeChat platform. The survey included a general information form; the Self-Rating Scale of Sleep (SRSS); the Depression, Anxiety, and Stress Scale-21 (DASS-21); the Perceived Social Support Scale (PSSS); and the Brief Resilience Scale (BRS). Data analysis was conducted using SPSS version 26.0. Statistical methods employed included t-tests, one-way analysis of variance (ANOVA), chi-square tests and Mann-Whitney U-tests for comparisons between groups. Pearson correlation coefficients were calculated to analyse the relationship between the SRSS score and the DASS-21, PSSS and BRS scores. A multiple linear stepwise regression analysis was conducted to determine the independent influencing factors of sleep quality.

RESULTS

More than 90% of the nurses were infected with COVID-19, and 60.6% had sleep disorders. The regression analysis revealed that anxiety, the BRS score, comorbidities, hospital grade, clinical front-line, age and COVID-19 infection independently predicted sleep quality. The scores for several SRSS items were higher than the Chinese norm, especially for the nurses in tertiary hospitals.

PATIENT AND PUBLIC CONTRIBUTION

No patient or public contribution.

Intubation of critically ill patients: A pilot study of minute-by-minute physiological changes within an Australian tertiary intensive care unit

BACKGROUND

There are no published minute-by-minute physiological assessment data for endotracheal intubation (ETT) performed in the intensive care unit (ICU). The majority of physiological data is available from Europe and North America where etomidate is the induction agent administered most commonly.

AIMS

The aim of this study was to describe the feasibility of obtaining minute-by-minute physiological and medication data surrounding ETT in an Australian tertiary ICU and to assess its associated outcomes.

METHODS

We performed a single-centre feasibility observational study. We obtained minute-by-minute data on physiological variables and medications for 15 min before and 30 min after ETT. We assessed feasibility as enrolled to screened patient ratio and completeness of data collection in enrolled patients. Severe hypotension (systolic blood pressure < 65 mmHg) and severe hypoxaemia (pulse oximetry saturation < 80%) were the secondary clinical outcomes.

RESULTS

We screened 43 patients and studied 30 patients. The median age was 58.5 (interquartile range: 49-70) years, and 18 (60%) were male. Near-complete (97%) physiological and medication data were obtained in all patients at all times. Overall, 15 (50%) ETTs occurred after hours (17:30-08:00) and 90% were by video laryngoscopy with a 90% first-pass success rate. Prophylactic vasopressors were used in 50% of ETTs. Fentanyl was used in all except one ETT at a median dose of 2.5 mcg/kg. Propofol (63%) or midazolam (50%) were used as adjuncts at low dose. Rocuronium was used in all but one patient. There were no episodes of severe hypotension and only one episode of short-lived severe hypoxaemia.

CONCLUSION

Minute-by-minute recording of ETT-associated physiological changes in the ICU was feasible but only fully available in two-thirds of the screened patients. ETT was based on fentanyl induction, low-dose adjunctive sedation, and frequent prophylactic vasopressor therapy and was associated with no severe hypotension and a single short-lived episode of severe hypoxaemia.

Using DaSilva Cone Operation to Establish 1.5 or 2 Ventricle Circulation After Initial Single Ventricle Palliation with Starnes Procedure

Ebstein anomaly (EA) is a congenital dysplasia of the tricuspid valve resulting in reduced right ventricular (RV) volume and tricuspid regurgitation. Severe EA in the neonatal period is associated with high mortality. The Starnes procedure (fenestrated RV exclusion) is reserved for EA patients with cardiogenic shock and has previously committed patients to single ventricle (SV) palliation. In this report, we present the results of a strategy to redirect patients utilizing the Da Silva Cone operation to achieve a 2 or 1.5 ventricle circulation. Single-center retrospective study including all consecutive cases of Da Silva Cone operation after Starnes procedure. Between 2019 and 2023, six conversions from Starnes procedure to Cone reconstruction were performed. All were critically ill before their Starnes procedure; four on extracorporeal membrane oxygenation. Two patients were successfully rerouted to a two-ventricle repair; the remainder to 1.5 ventricle circulation. RV pressure estimates showed no correlation with success. Post-Cone intensive care and hospital stays were brief, median 5 and 6 days, respectively. All are between 2.5 and 6 years old, without indications for SV palliation. There were no deaths, with follow up ranging 1 month-4 years. No repeat interventions were performed on the tricuspid valves. One subject had a surgical pulmonary valve replacement. Tricuspid regurgitation was mild in all. The Da Silva Cone operation offers successful redirection of EA patients from a SV pathway to a 1.5 or 2 ventricle pathway after Starnes procedure. The approach is feasible and durable in midterm follow-up. The decision to initially proceed with Starnes need not be an irrevocable decision to continue down a SV palliation pathway.

Social media "SoMe" in neuro-oncology: a review of the literature

PURPOSE

This article examines the current state of social media (SoMe) in neuro-oncology and neurosurgical oncology. The goal of this paper is to provide thorough discourse regarding benefits and disadvantages of being a neurosurgical oncologist on SoMe, while discussing the place SoMe will have in cranial tumor-based practices going forward.

METHODS

The author's performed a rigorous literature review on the topic. Included information was pertinent to the history of SoMe in neurosurgical oncology and its impact on the field of neuro-oncology. Incorporated as well are the benefits of being a neurosurgical oncologist on SoMe, the drawbacks of participation on SoMe platforms, and knowledge that facilitates discussion about the future of SoMe in neurosurgical oncology.

RESULTS

SoMe plays an important role in neuro-oncology and neurosurgical oncology. SoMe continues to exponentially grow in the healthcare sphere as more providers utilize SoMe platforms. We report objective negative and positive outcomes of SoMe in neurosurgical oncology and neuro-oncology. Here, we summarize these results and provide dialogue describing the effect SoMe is having on the many different aspects of neurosurgical oncology and neuro-oncology.

CONCLUSION

Although SoMe platforms improve social presence and patient outreach, the use of SoMe can also adversely affect one's career by exposing clinicians to unchecked societal, legal and professional consequences. While using SoMe as a vessel to propagate career initiatives, neurosurgical oncologists should exercise caution with the content they choose to circulate.

Retropharyngeal carotid body tumor: A challenge in terms of surgical technicality

INTRODUCTION AND IMPORTANCE

Carotid body tumors are rare neoplasms originating from neural crest cells, commonly presenting as a painless, slow-growing mass in the lateral neck. The retropharyngeal variant of these tumors is particularly uncommon, with an incidence of approximately 2.6 %.

CASE PRESENTATION

A 50-year-old man presented to the Otolaryngology Department at Rasoul Akram Hospital with a painless 3 × 4 cm mass on the right side of his neck, which had gradually increased in size. Clinical examination revealed a pulsatile, nontender mass exerting pressure on the right lateral aspect of the pharynx. A CT scan showed a well-defined, enhancing retropharyngeal mass located between the internal and external carotid arteries on the right side, suggestive of a carotid body tumor. The patient underwent surgical resection, achieving complete tumor removal without complications. A four-year follow-up revealed no signs of tumor recurrence.

CLINICAL DISCUSSION

Carotid body tumors are indolent masses. Diagnosis typically involves clinical evaluation, supplemented by imaging techniques such as ultrasound, CT scan, and MRI, which aid in delineating the tumor's morphology and dimensions. Surgical resection remains the preferred treatment, aiming to achieve complete tumor excision while preserving blood flow, avoiding damage to critical organs and nerves, and safeguarding brain function.

CONCLUSION

The retropharyngeal location of carotid body tumors represents an exceptionally rare variant, and their surgical resection presents a significant challenge for surgeons. This case report offers crucial insights into the surgical management of a retropharyngeal carotid body tumor, serving as a valuable resource for future surgeons who may face similar cases.