Sequential rupture of two concomitant cerebral aneurysms

The diagnosis of multiple cerebral aneurysms in patients with a spontaneous aneurysmal subarachnoid haemorrhage is not uncommon. The incidence of rupture from a second aneurysm, whilst the patient is recovering from a first bleed is however extremely rare. We report a 21-year-old female with a WFNS grade 1 subarachnoid haemorrhage secondary to a ruptured 5mm right posterior communicating artery aneurysm which was secured with clipping. Sixteen days later, whilst an in-patient, she suffered a second SAH from a left anterior choroidal artery aneurysm which was subsequently coiled. Comparison of digital subtraction angiography showed an almost doubling of the aneurysm from 2.7x2 mm to 4.4x2.3 mm. We review the literature of previously reported simultaneous and sequential aneurysmal subarachnoid haemorrhage and add to the sparse literature on this rare phenomena.

The global syndemic of metabolic diseases in the young adult population: a consortium from the Global Burden of Disease 2000-2019

Funding Acknowledgements

Type of funding sources: None.

Background

A large proportion of premature deaths are related to metabolic diseases in the young adult population. We examined the global trends and mortality of metabolic diseases using estimates from the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) 2019 in individuals aged below 40 years.

Methods

From 2000-2019, global estimates of prevalence, deaths, and disability-adjusted life years (DALYs) were described for metabolic diseases (type 2 diabetes mellitus [T2DM], hypertension, non-alcoholic fatty liver disease [NAFLD]). Global estimates were limited to mortality and DALYs for risk factors (hyperlipidemia and obesity). Subgroup analyses were performed based on sex, geographical regions and Socio-Demographic Index (SDI). Age-standardized prevalence, death, and DALYs were presented per 100,000 population with 95% uncertainty intervals (UI).

Findings

The prevalence for all metabolic diseases increased from 2000-2019, with the most pronounced increase in males and high SDI countries. In 2019, the highest age-standardised death rates were observed in hypertension (133·88 [121·25-155·73]; males, 160·13 [138·91-180·79]; females, 119·66 [102·33-136·86]), followed by obesity (62·59 [39·92-89·13]; males, 66·55 [39·76-97·21]; females, 58·14 [38·53-81·39]), hyperlipidemia (56·51 [41·83-73·62]; males, 67·33 [50·78-86·43]; females, 46·50 [32·70-62·38]), T2DM (18·49 [17·18-19·66]; males, 19·94 [18·50-21·32]; females, 17·30 [15·62-18·70]) and NAFLD (2·09 [1·61-2·60]; males, 2·38 [1·82-3·02]; females, 1·82 [1·41-2·27]). Similarly, obesity (1932·54 [1276·61-2639·74]) had the highest age-standardised DALYs, followed by hypertension (2885·57 [2580·75-3201·05]), hyperlipidemia (1207·15 [975·07-1461·11]), T2DM (801·55 [670·58-954·43]) and NAFLD (53·33 [40·73-68·29]). Mortality rates decreased over time in hyperlipidemia (-60%), hypertension (-47%), NAFLD (-31%) and T2DM (-20%), but not in obesity (107% increase). The highest metabolic-related mortality was observed in the Eastern Mediterranean and low SDI countries.

Conclusion

The growing prevalence of metabolic diseases, increasing obesity-related mortality trends, and the sex-regional-socioeconomic disparities evident in young adulthood, present the concerning global burden of metabolic diseases now and in the years ahead.

Higher risk of adverse cardiovascular outcomes in women with type 2 diabetes mellitus: an umbrella review of systematic reviews

Funding Acknowledgements

Type of funding sources: None.

Background

Previous studies have shown that females with type 2 diabetes mellitus (T2DM) may have an excess mortality risk compared to males. Furthermore, other studies have reported sex differences in managing cardiovascular risk factors, such as controlling hypertension and hypercholesterolemia.

Purpose

With the growing evidence from systematic reviews examining the sex differences in cardiovascular outcomes for patients with T2DM, an umbrella review is an essential next step to synthesising and assessing the strength of the available evidence.

Methods

Medline and Embase were searched from inception till 7th August 2022 for systematic reviews and meta-analyses studying the effects of sex on cardiovascular outcomes in T2DM patients. Results from reviews were synthesised with a narrative synthesis, with a tabular presentation of findings and forest plots for reviews that performed a meta-analysis. AMSTAR 2 tool was used to assess the methodological quality of included reviews, while the GRADE assessment was used to assess the quality of evidence for outcomes.

Results

A total of 28 studies evaluating sex differences in cardiovascular outcomes were included. Females with T2DM had a higher risk of developing coronary heart disease (CHD; RRR 1.52, 95%CI 1.32–1.76, p<0.001), acute coronary syndrome (ACS; RRR 1.38, 95%CI 1.25–1.52, p<0.001), and heart failure (RRR 1.09, 95%CI 1.05–1.13, p<0.001) than males. In terms of mortality outcomes, females had a higher risk of all-cause mortality (RRR 1.13, 95%CI 1.07–1.19, p<0.001), cardiac mortality (RRR 1.49, 95%CI 1.11–2.00, p=0.009) and CHD mortality (RRR 1.44, 95%CI 1.20–1.73, p<0.001) as compared to males. In patients undergoing percutaneous coronary intervention, females reported higher odds of MACE (OR 1.49, 95%CI 1.07–2.07, p=0.020) and all-cause mortality (OR 1.71, 95%CI 1.46–2.00, p<0.001) compared to males. Females in Asia (RRR 1.12, 95%CI 1.03–1.21, p=0.006) and North America (RRR 1.10, 95%CI 1.08–1.12, p<0.001) were at increased risk of all-cause mortality while females in Western countries had an increased risk for cardiac death (RRR 1.84, 95%CI 1.45–2.32, p<0.001) compared to males. Six reviews were rated as high in quality; eight reviews were rated as moderate, and fourteen reviews were rated as low in quality. Regarding the quality of outcomes, all outcomes in non-interventional studies had a moderate quality of evidence, while all outcomes in interventional studies achieved a high quality of evidence.

Conclusions

This umbrella review evaluated the quality of meta-analyses and demonstrated that females with T2DM have a higher risk of cardiovascular outcomes than their male counterparts. Future studies examining the sex differences in outcomes should attempt to address the heterogeneity and epidemiological factors for a better quality of evidence. Policymakers should consider sex-specific differences in implementing effective tailored strategies to tackle T2DM.

Effects of epicardial adipose tissue volume and thickness assessed by computed tomography and echocardiography on cardiovascular and cerebrovascular outcomes: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Epicardial adipose tissue (EAT) has garnered attention as a potential imaging biomarker for the risk stratification of cardiovascular diseases (CVD). However, the prognostic utility of EAT due to inter-ethnic differences and imaging modality (computed tomography (CT) or transthoracic echocardiography (TTE)) remains undetermined.

Purpose

To evaluate the effect of EAT volume and thickness on cardiovascular and cerebrovascular outcomes. We also aim to compare the prognostic utility between CT volumetric and TTE thickness quantification; and provide consolidated data on the heterogeneity in EAT measurements across different ethnic groups.

Methods

Medline and Embase databases were searched from inception till 16 May 2022 for studies that measured EAT volume or thickness of adult patients at baseline and reported follow-up data on outcomes of interest. Outcomes included MACE, all-cause mortality, cardiac death, myocardial infarction (MI), coronary revascularisation, atrial fibrillation (AF), and stroke. Statistical analyses were conducted on Review Manager 5.4.1 to obtain unadjusted and adjusted hazard ratios (HR) and odds ratios (OR) with the results presented on forest plots.

Results

Twenty-nine studies comprising 19709 patients were included in our analysis. Increased EAT thickness and volume were associated with higher risks of MACE (adjusted HR [aHR] 1.46, 95%CI 1.25–1.71, p<0.001), cardiac death (OR 2.53, 95%CI 1.17–5.44, p=0.020), MI (OR 2.63, 95%CI 1.39–4.96, p=0.003), coronary revascularisation (OR 2.99, 95%CI 1.64–5.44, p<0.001), AF (aOR 4.04, 95%CI 3.06–5.32, p<0.001), and stroke (HR 1.02, 95%CI 1.01–1.03, p<0.001). CT-volumetric quantification of EAT conferred a larger MACE risk (aHR 1.79, 95%CI 1.47–2.17, p<0.001) compared to TTE thickness quantification (aHR 1.20, 95%CI 1.09–1.32, p<0.001). Studies originating from North America (HR 1.91, 95%CI 1.26–2.89, p=0.002) and Asia (HR 1.60, 95%CI 1.09–2.36, p=0.020) demonstrated a significantly higher risk of MACE with increased EAT thickness and volume. However, this significance was not seen in European studies (HR 1.48, 95%CI 0.99–2.20, p=0.060). Subgroup differences were also noted across the studies’ countries of origin when analysing the association of EAT and MI (p=0.020). European studies reported a higher magnitude of MI risk associated with higher EAT thickness and volume (OR 5.28, 95%CI 2.34–11.95, p<0.001) as compared to Asian studies (OR 1.75, 95%CI 1.05–2.92, p=0.030). No differences were noted across other outcomes in the subgroup comparisons by geographical region and between CT and TTE quantification of EAT.

Conclusion

The utility of EAT as an imaging biomarker for predicting and prognosticating CVD is promising. Future efforts to harmonise the EAT parameter thresholds, based on the type of imaging modality and the target population’s ethnic characteristics, will be the next important step before including EAT in CVD prediction models.

Subtarsal Versus Transconjunctival Approach: A Long-Term Follow-Up of Esthetic Outcomes and Complications

PURPOSE

There is limited data that compares the long-term esthetic outcomes in patients who undergo traumatic orbital reconstruction with the subtarsal (STA) and transconjunctival approaches. The purpose of this study is to determine the long-term differences in scarring, cosmesis, and complications between the 2 approaches.

MATERIALS AND METHODS

Sixty-seven patients were examined on average 39 months after surgery. Each patient was evaluated for satisfaction in surgical scarring and complications including diplopia, nerve paresthesia, lid malposition, and epiphora. Photographic images of each patient were reviewed by 3 experienced maxillofacial surgeons and 3 nonmedical personnel to determine if scarring was present and quantify it using the Manchester scar scale (MSS). Scarring was then compared using 3 different objective scales; MSS, modified Vancouver scar scale and the modified Stony Brook scar evaluation scale. Recorded data were analyzed using the χ² test and Fisher exact test to determine statistical significance (P < .05).

RESULTS

No visible scar formation was seen in 61 to 76.5% of patients who had an STA using either of the 3 scales, although the MSS proved to be significantly more accurate when assessing linear periorbital scars than the modified Vancouver scar scale and Stony Brook scar evaluation scale (P < .001). Surgeons were able to correctly identify subtarsal scars in 26.3% of patients, in comparison with the nonmedically trained people identifying just 10.6% of scars. Most of these showed only mild scar formation and are unlikely to have any significant effect on patient's quality-of-life. Overall, 93.3% of patients who had an STA were satisfied with the scar formation.

CONCLUSIONS

While the transconjunctival approach is a useful technique that offers a surgical approach with no scarring, over the long-term, only a small proportion of STA scars are visible to the average person. Surgeons should consider both approaches and their clinical advantages when treating patients with traumatic orbital injuries.

Dissecting the dynamics of signaling events in the BMP, WNT, and NODAL cascade during self-organized fate patterning in human gastruloids

During gastrulation, the pluripotent epiblast self-organizes into the 3 germ layers-endoderm, mesoderm and ectoderm, which eventually form the entire embryo. Decades of research in the mouse embryo have revealed that a signaling cascade involving the Bone Morphogenic Protein (BMP), WNT, and NODAL pathways is necessary for gastrulation. In vivo, WNT and NODAL ligands are expressed near the site of gastrulation in the posterior of the embryo, and knockout of these ligands leads to a failure to gastrulate. These data have led to the prevailing view that a signaling gradient in WNT and NODAL underlies patterning during gastrulation; however, the activities of these pathways in space and time have never been directly observed. In this study, we quantify BMP, WNT, and NODAL signaling dynamics in an in vitro model of human gastrulation. Our data suggest that BMP signaling initiates waves of WNT and NODAL signaling activity that move toward the colony center at a constant rate. Using a simple mathematical model, we show that this wave-like behavior is inconsistent with a reaction-diffusion-based Turing system, indicating that there is no stable signaling gradient of WNT/NODAL. Instead, the final signaling state is homogeneous, and spatial differences arise only from boundary effects. We further show that the durations of WNT and NODAL signaling control mesoderm differentiation, while the duration of BMP signaling controls differentiation of CDX2-positive extra-embryonic cells. The identity of these extra-embryonic cells has been controversial, and we use RNA sequencing (RNA-seq) to obtain their transcriptomes and show that they closely resemble human trophoblast cells in vivo. The domain of BMP signaling is identical to the domain of differentiation of these trophoblast-like cells; however, neither WNT nor NODAL forms a spatial pattern that maps directly to the mesodermal region, suggesting that mesoderm differentiation is controlled dynamically by the combinatorial effect of multiple signals. We synthesize our data into a mathematical model that accurately recapitulates signaling dynamics and predicts cell fate patterning upon chemical and physical perturbations. Taken together, our study shows that the dynamics of signaling events in the BMP, WNT, and NODAL cascade in the absence of a stable signaling gradient control fate patterning of human gastruloids.

Universal wave-number selection laws in apical growth

We study pattern-forming dissipative systems in growing domains. We characterize classes of boundary conditions that allow for defect-free growth and derive universal scaling laws for the wave number in the bulk of the domain. Scalings are based on a description of striped patterns in semibounded domains via strain-displacement relations. We compare predictions with direct simulations in the Swift-Hohenberg, the complex Ginzburg-Landau, the Cahn-Hilliard, and reaction-diffusion equations.

Obesity Prevalence and Associated Outcomes in Cardiothoracic Patients: A Single-Centre Experience

The objective of this study was to investigate the prevalence of obesity and its relationship with adverse outcomes in ICU cardiothoracic patients. We performed a retrospective analysis of cardiothoracic patients admitted to The Royal Melbourne Hospital ICU between 2002 and 2014. Eight thousand and sixty-four patients who underwent coronary artery bypass, valve replacement/repair, or both, were divided into six categories of body mass index using World Health Organization criteria. Prevalence of obesity over time in the ICU was measured and compared to prevalence of obesity in the adult Australian population. The association between obesity and adverse postoperative outcomes was then analysed. Obesity is currently 1.2 times more prevalent in the Royal Melbourne Hospital ICU cardiothoracic patients than in the adult Australian population, with 33.5% of patients having a body mass index ≥30 kg/m2. Over time, this was relatively constant, but an increasing proportion were morbidly obese. Obesity, but not morbid obesity, was associated with reduced 30-day mortality (odds ratio [OR] 0.41). Both obese and morbidly obese patients had reduced odds of return to theatre for bleeding (OR 0.49 and OR 0.19, respectively), but increased odds of new-onset renal failure (OR 1.62 and OR 3.17, respectively). Morbidly obese patients had double the odds of an ICU stay longer than 14 days (OR 2.05). In summary, a growing proportion of our obese ICU patients are morbidly obese, with a dramatically increased length of ICU stay. This has major implications for resource allocation in the ICU, and may inform modelling of future bed utilisation. Obesity, but not morbid obesity, conferred a mortality benefit.

Management of dental infections by medical practitioners

BACKGROUND

Patients with dental infections frequently present to primary care practitioners such as emergency physicians or general practitioners. It is important for these healthcare professionals to understand how to assess and treat such conditions, including when to refer and to whom.

OBJECTIVE

This article aims to cover basic principles of managing patients with dental infections who present to emergency departments or general practice surgeries.

DISCUSSION

Maxillofacial surgeons frequently see serious cases of facial and neck infections that can easily be prevented if appropriately managed early.

The use of intravenous contrast in postoperative MR imaging of pituitary macroadenomas

In this study we reviewed 23 postoperative magnetic resonance (MR) imaging examinations of patients with pituitary macroadenomas to determine if intravenous contrast is of value in this setting. The addition of contrast enhanced images to noncontrast T1-weighted images changed the radiologist's assessment in 4/5 early postoperative examinations and in 0/18 late postoperative examinations. Intravenous contrast is of value in distinguishing residual tumor from packing material on early postoperative MR examinations but is less useful in later postoperative examinations.

[Delayed hypoxia after the surgical correction of femoral neck fracture]

We investigated perioperative blood gas changes in 26 patients scheduled for surgical correction of femoral neck fracture under epidural anesthesia. Arterial blood gases during spontaneous air respiration were measured eight times during the femoral neck prosthetic replacements (n = 16), and four times during osteosynthesis (n = 10). In the patients who received femoral neck replacements using bone cement (n = 8), arterial oxygen tension decreased significantly four hours after insertion of prosthesis, and did not recover during two postoperative days. In contrast, in the patients who received cementless femoral neck replacements (n = 8), arterial oxygen tension tended to decrease but not significantly, and returned to normal on the second postoperative day. In the patients who received osteosynthesis, arterial oxygen tension did not change. We suspected that the causes of delayed hypoxia in the femoral neck replacements were vascular endothelial cell injury in the lung by free fatty acid originating from fat embolism, and/or microthrombosis resulting from activated coagulation system. Bone cement was thought to intensify fat embolism because of elevated intramedullary pressure in the femur.

[Is thoracic epidural anesthesia beneficial to myocardial ischemia?--Influence of hemodynamics]

The effects of thoracic epidural anesthesia (TEA) on regional myocardial blood flow (RMBF) and hemodynamics were evaluated in open-chest dogs with coronary artery stenosis. In the 6 dogs with pressure-rate quotients (PRQ) of greater than 0.8, TEA caused a significant increase of the ratio of endocardial to epicardial RMBF in the ischemic region and tended to increase the ratio of RMBF in the ischemic to normal area, resulting in improved myocardial ischemia. There was no reduction of myocardial ischemia in the 11 dogs with PRQ of less than 0.8. The hemodynamic effects determine whether TEA is favorable for the ischemic heart or not. It appears that PRQ is useful as an indicator of myocardial oxygen balance during TEA.

[Effects of sevoflurane, isoflurane, and halothane on regional myocardial blood flow in the ischemic canine heart]

The effects of sevoflurane (Sev), isoflurane (Iso), and halothane (Hal) on coronary circulation were studied in 30 dogs with acute coronary arterial stenosis. Regional myocardial blood flow (rMBF) was measured by hydrogen clearance method. There was no significant difference between each anesthetic agent in heart rate, mean arterial pressure, and cardiac output under any anesthesia level. As the inspired concentration of each anesthetic is increased, rMBF decreased significantly and rMBF/rate-pressure-product (RPP) ratio increased in normal area. In Sev and Iso groups, rMBF/RPP ratios were higher than that in Hal group, suggesting luxury perfusion caused by Sev and Iso. In the ischemic area, rMBF was reduced depending on the inspired concentration of each anesthetic agent and transmural maldistribution of blood flow was not observed with any anesthetic agent. Nevertheless the ratio of rMBF in ischemic area to that of normal area was decreased in Sev and Iso groups, but not in Hal group. In this study, neither Sev nor Iso worsened regional myocardial ischemia. However, Sev-induced coronary vasodilation may cause regional myocardial ischemia by redistribution of flow under steal prone condition.

[Recovery from cardiac arrest by prostaglandin E1 infusion during emergency open heart surgery]

A 21 day old infant, diagnosed as ASD, VSD, and PDA, was scheduled for an emergency radical operation. After admission, she fell into cardiac failure and was treated with artificial ventilation and infusion of inotropic agents. Anesthesia was induced with fentanyl and maintained with continuous fentanyl infusion and chlorpromazine. Dopamine and dobutamine were administered before she underwent a cor-pulmonary by-pass. At the time of release of aortic clamping, her blood pressure went down and dopamine, dobutamine and isoproterenol were administered. After completion of the cor-pulmonary by-pass, tachy-arrhythmia and hypotension occurred. Digitalis and calcium did not reverse the condition. The thorax was reopened and BP rose. After 15 min, ventricular fibrillation occurred. Defibrillation was carried out, but the heart was arrested. Even with pacing and cardiac massage, cardiac contraction did not resume. However immediately on intravenous administration of PGE1, 40 ng.kg-1.min-1, the heart started to beat. The cause of recovery from cardiac arrest was speculated to be due to reuptake of intracellular Ca2+ by PGE1. We stress therefore, that during and after cor-pulmonary by-pass procedures, PGE1 infusion may be beneficial.