Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Learning Curve for Flow Diversion of Posterior Circulation Aneurysms: A Long-Term International Multicenter Cohort Study

BACKGROUND AND PURPOSE

Flow diversion has gradually become a standard treatment for intracranial aneurysms of the anterior circulation. Recently, the off-label use of the flow diverters to treat posterior circulation aneurysms has also increased despite initial concerns of rupture and the suboptimal results. This study aimed to explore the change in complication rates and treatment outcomes across time for posterior circulation aneurysms treated using flow diversion and to further evaluate the mechanisms and variables that could potentially explain the change and outcomes.

MATERIALS AND METHODS

A retrospective review using a standardized data set at multiple international academic institutions was performed to identify patients with ruptured and unruptured posterior circulation aneurysms treated with flow diversion during a decade spanning January 2011 to January 2020. This period was then categorized into 4 intervals.

RESULTS

A total of 378 procedures were performed during the study period. Across time, there was an increasing tendency to treat more vertebral artery and fewer large vertebrobasilar aneurysms (P = .05). Moreover, interventionalists have been increasingly using fewer overlapping flow diverters per aneurysm (P = .07). There was a trend toward a decrease in the rate of thromboembolic complications from 15.8% in 2011-13 to 8.9% in 2018-19 (P = .34).

CONCLUSIONS

This multicenter experience revealed a trend toward treating fewer basilar aneurysms, smaller aneurysms, and increased usage of a single flow diverter, leading to a decrease in the rate of thromboembolic and hemorrhagic complications.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Do Outcomes between Women and Men Differ after Endovascular Thrombectomy? A Meta-analysis

BACKGROUND

Research on the presence of sex-based differences in the outcomes of patients undergoing endovascular thrombectomy for acute ischemic stroke has reached differing conclusions.

PURPOSE

This review aimed to determine whether sex influences the outcome of patients with large-vessel occlusion stroke undergoing endovascular thrombectomy.

STUDY SELECTION

We performed a systematic review and meta-analysis of endovascular thrombectomy studies with either stratified cohort outcomes according to sex (females versus males) or effect size reported for the consequence of sex versus outcomes. We included 33 articles with 7335 patients.

DATA ANALYSIS

We pooled ORs for the 90-day mRS score, 90-day mortality, symptomatic intracranial hemorrhage, and recanalization.

DATA SYNTHESIS

Pooled 90-day good outcomes (mRS ≤ 2) were better for men than women (OR = 1.29; 95% CI, 1.09-1.53; P = <.001, I² = 56.95%). The odds of the other outcomes, recanalization (OR = 0.94; 95% CI, 0.77-1.15; P = .38, I² = 0%), 90-day mortality (OR = 1.11; 95% CI, 0.89-1.38; P = .093, I² = 0%), and symptomatic intracranial hemorrhage (OR = 1.40; 95% CI, 0.99-1.99; P = .069, I² = 0%) were comparable between men and women.

LIMITATIONS

Moderate heterogeneity was found. Most studies included were retrospective in nature. In addition, the randomized trials included were not specifically designed to compare outcomes between sexes.

CONCLUSIONS

Women undergoing endovascular thrombectomy for large-vessel occlusion have inferior 90-day clinical outcomes. Sex-specific outcomes should be investigated further in future trials as well as pathophysiologic studies.

Intracranial angiomatoid fibrous histiocytoma with Hodgkin lymphoma

Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue tumour of uncertain differentiation and low metastatic potential, which occurs predominantly in children and young adults. It occurs mostly within the extremities, trunk, head and neck. We report the case of a 32-year-old female that was operated in our hospital in 2016 and twice in 2017. The patient had headaches and neck pain initially in 2016. We discuss the radiographic and histologic features initially found and the findings that ultimately led to the diagnosis of AFH. The patient had a past history of Hodgkin lymphoma.

Prevalence of hock, knee, and neck skin lesions and associated risk factors in dairy herds in the Maritime Provinces of Canada

Skin lesions are commonly seen in dairy herds and have been associated with animal-, environmental-, and management factors. These lesions are not only a welfare concern, but they also affect profitability. Three areas on the cattle were examined for skin lesions: the hock, knee, and neck. Previous Canadian studies estimating the prevalence of lesions and the risk factors associated with them have not included the Maritime Provinces. In this study, 73 herds in the Maritime Provinces were chosen voluntarily to participate, with both tiestalls (n = 33) and freestalls (n = 40) represented. Within each herd, 67 to 90% of the lactating cows were selected and assessed for potential animal-, environmental-, and management-based risk factors. If producers were aware of the potential risk factors, this could help them reduce the prevalence in their herd. Leg lesions were scored on a 4-point scale (0-3) based on hair loss, swelling, and scabs, with a lesion defined as a score of 2 or 3 on at least 1 hock or knee. Necks were scored on a 3-point scale (0-2), with a lesion defined as score 2. For freestalls, the prevalence (95% confidence interval) of hock lesions was 39% (29-49%), knee lesions was 14% (11-18%), and neck lesions was 1% (<1-2%). Similarly, for tiestalls the prevalence (95% confidence interval) of hock lesions was 39% (33-46%), knee lesions was 17% (13-22%), and neck lesions was 5% (3-8%). Due to differences in management and methods of assessment between facility types, tiestalls and freestalls were analyzed separately. Due to dichotomization of cows as having a skin lesion or not, random-effects multivariable logistic regression was used to determine the risk factors for each lesion and facility type. Several environmental-based measurements, such as the stall base, type and dryness of bedding, and type of milking parlor, were associated with leg lesions. An environmental-based measurement that was associated with neck lesions was the design of the feed rail barrier in freestalls and the dimensions of the tie rail in tiestalls. Animal-based risk factors, such as stage of lactation, parity, and body condition, were also associated with all 3 types of lesions. This study showed that lesions to the hock, knee, and neck were common in the Maritime Provinces of Canada. Although differences were seen between facility types, in general, the results suggest that improving stall design and management and feed bunk design would help producers reduce the number of skin lesions seen in dairy cattle.

Prevalence of lameness and associated risk factors on dairy farms in the Maritime Provinces of Canada

Lameness in dairy cattle is a major issue for the industry due to the effects on the welfare of the animal, the economic impact, and consumer perception. The aim of this study was to determine the prevalence of lameness and explore potential risk factors in the Maritime Provinces of Canada. Cows were scored for lameness and potential risk factors and were assessed in 46 freestall herds and 33 tiestall herds in Nova Scotia, New Brunswick, and Prince Edward Island. In freestall herds, lameness was assessed using the most common method, locomotion scoring. A cow with a gait score of ≥3 out of 5 was considered to be lame. In tiestall herds, lameness was assessed using an alternative method known as stall lameness scoring. This assessment consisted of observation of the cow for 4 behavioral changes: standing on the edge of the stall, shifting weight, resting a limb, and uneven weight bearing when moved side to side. A cow displaying 2 or more of these behaviors was considered to be lame. At the time of the assessment, other animal-, environmental-, and management-based measurements were collected. These measurements were used in multivariable logistic regression analysis to determine risk factors that were associated with lameness for both freestalls and tiestalls independently. The prevalence of lameness was 21% for freestall-housed cattle and 15% for tiestall-housed cattle. Of the 1,488 tiestall-housed cows that were assessed, 68% showed no behavioral changes, whereas 15, 15, 2, and <1% showed 1, 2, 3, or 4 changes, respectively. In freestalls, higher odds of lameness were seen when cows spent ≥3 h/d in the holding area for milking compared with those that spent <3 h/d. In tiestall herds, higher odds of lameness were seen when bedding material was wet compared with when it was dry. For both lactating cow facility types, housing the dry cows and heifers on a deep bedded pack compared with tiestalls or freestalls was associated with a decreased odds of lameness. There were also many cow-level variables associated with lameness, including parity, daily milk production, stage of production, body condition, and width at the tuber coxae (hook bones). If producers become aware of the risk factors associated with lameness, they can make informed decisions on where to implement changes to help reduce the level of lameness in their herd.

Prospective Multicenter Study of Changes in MTT after Aneurysmal SAH and Relationship to Delayed Cerebral Ischemia in Patients with Good- and Poor-Grade Admission Status

BACKGROUND AND PURPOSE

Patients with aneurysmal SAH and good clinical status at admission are considered at a lower risk for delayed cerebral ischemia. Prolonged MTT may be associated with an increased risk. It is unclear whether this is dependent on clinical status. Our purpose was to determine whether increased MTT within 3 days of aneurysmal SAH compared with baseline is associated with a higher risk of delayed cerebral ischemia in patients with good (World Federation of Neurosurgical Societies I-III) versus poor (World Federation of Neurosurgical Societies IV-V) admission status.

MATERIALS AND METHODS

This prolonged MTT was a multicenter, prospective cohort investigation of 87 patients with aneurysmal SAH. MTT was measured at admission before aneurysm treatment (MTT1) and following repair (MTT2) within 3 days of admission; MTT_diff was calculated as the difference between MTT2 and MTT1. Changes in MTT across time were assessed with repeated measures analyses. Risk of delayed cerebral ischemia or death was determined with multivariate logistic regression analysis.

RESULTS

In patients with a good grade (n = 49), MTT was prolonged in patients who developed delayed cerebral ischemia, with MTT_diff significantly greater (0.82 ± 1.5) compared with those who did not develop delayed cerebral ischemia (-0.14 ± 0.98) (P = .03). Prolonged MTT was associated with a significantly higher risk of delayed cerebral ischemia or death (OR = 3.1; 95% CI, 1.3-7.4; P = .014) on multivariate analysis. In patients with poor grades (n = 38), MTT_diff was not greater in patients who developed delayed cerebral ischemia; MTT1 was significantly prolonged compared with patients with a good grade.

CONCLUSIONS

Patients in good clinical condition following aneurysmal SAH but with increasing MTT in the first few days after aneurysmal SAH are at high risk of delayed cerebral ischemia and warrant close clinical monitoring.

Differentiation of Enhancing Glioma and Primary Central Nervous System Lymphoma by Texture-Based Machine Learning

BACKGROUND AND PURPOSE

Accurate preoperative differentiation of primary central nervous system lymphoma and enhancing glioma is essential to avoid unnecessary neurosurgical resection in patients with primary central nervous system lymphoma. The purpose of the study was to evaluate the diagnostic performance of a machine-learning algorithm by using texture analysis of contrast-enhanced T1-weighted images for differentiation of primary central nervous system lymphoma and enhancing glioma.

MATERIALS AND METHODS

Seventy-one adult patients with enhancing gliomas and 35 adult patients with primary central nervous system lymphomas were included. The tumors were manually contoured on contrast-enhanced T1WI, and the resulting volumes of interest were mined for textural features and subjected to a support vector machine-based machine-learning protocol. Three readers classified the tumors independently on contrast-enhanced T1WI. Areas under the receiver operating characteristic curves were estimated for each reader and for the support vector machine classifier. A noninferiority test for diagnostic accuracy based on paired areas under the receiver operating characteristic curve was performed with a noninferiority margin of 0.15.

RESULTS

The mean areas under the receiver operating characteristic curve were 0.877 (95% CI, 0.798-0.955) for the support vector machine classifier; 0.878 (95% CI, 0.807-0.949) for reader 1; 0.899 (95% CI, 0.833-0.966) for reader 2; and 0.845 (95% CI, 0.757-0.933) for reader 3. The mean area under the receiver operating characteristic curve of the support vector machine classifier was significantly noninferior to the mean area under the curve of reader 1 (P = .021), reader 2 (P = .035), and reader 3 (P = .007).

CONCLUSIONS

Support vector machine classification based on textural features of contrast-enhanced T1WI is noninferior to expert human evaluation in the differentiation of primary central nervous system lymphoma and enhancing glioma.

Small pipes: preliminary experience with 3-mm or smaller pipeline flow-diverting stents for aneurysm repair prior to regulatory approval

Flow diversion has become an established treatment option for challenging intracranial aneurysms. The use of small devices of ≤3-mm diameter remains unapproved by major regulatory bodies. A retrospective review of patients treated with Pipeline Embolization Devices of ≤3-mm diameter at 3 Canadian institutions was conducted. Clinical and radiologic follow-up data were collected and reported. Twelve cases were treated with ≥1 Pipeline Embolization Device of ≤3-mm diameter, including 2 with adjunctive coiling, with a median follow-up of 18 months (range, 4-42 months). One patient experienced a posttreatment minor complication (8%) due to an embolic infarct. No posttreatment hemorrhage or delayed complications such as in-stent stenosis/thrombosis were observed. Radiologic occlusion was seen in 9/12 cases (75%) and near-occlusion in 2/12 cases (17%). Intracranial aneurysm treatment with small-diameter flow-diverting stents provided safe and effective aneurysm closure in this small selected sample. These devices should be further studied and considered for regulatory approval.

Behavioural and faecal glucocorticoid metabolite responses of single caging in six cats over 30 days

OBJECTIVES

The aim was to characterize the behaviour and faecal glucocorticoid metabolite (FGM) responses of six cats (Felis catus) to single caging for 30 days.

DESIGN

In this observational study, changes in outcome measures were monitored with habituation to caging. Continuous focal observations of the activity, location in the cage, and posture were conducted from video recordings for one 24-hour period/week/cat. Cat-Stress-Scores were recorded daily. All faecal samples were collected for analysis of FGM.

RESULTS

The percentage time spent eating increased, while percentage time spent grooming decreased, from week 1 to week 2. Cat-Stress-Score declined significantly from week 1 to week 2. FGM concentrations were significantly greater in week 1 than in week 5. A posthabituation time budget of the behaviour of the cats in the single cages showed that inactivity dominated the time budget and the cats were located on the shelf almost half of the time.

CONCLUSIONS

Results suggests that a shelf was a resource of value to the cats, and that its inclusion in enclosure design is important. Quantitative and qualitative behavioural data indicated that there was an initial stress response to caging that stabilised after the first week, while FGM concentration took longer to stabilise.

A randomized clinical trial of high-dosage coenzyme Q10 in early Parkinson disease: no evidence of benefit

IMPORTANCE

Coenzyme Q10 (CoQ10), an antioxidant that supports mitochondrial function, has been shown in preclinical Parkinson disease (PD) models to reduce the loss of dopamine neurons, and was safe and well tolerated in early-phase human studies. A previous phase II study suggested possible clinical benefit.

OBJECTIVE

To examine whether CoQ10 could slow disease progression in early PD.

DESIGN, SETTING, AND PARTICIPANTS

A phase III randomized, placebo-controlled, double-blind clinical trial at 67 North American sites consisting of participants 30 years of age or older who received a diagnosis of PD within 5 years and who had the following inclusion criteria: the presence of a rest tremor, bradykinesia, and rigidity; a modified Hoehn and Yahr stage of 2.5 or less; and no anticipated need for dopaminergic therapy within 3 months. Exclusion criteria included the use of any PD medication within 60 days, the use of any symptomatic PD medication for more than 90 days, atypical or drug-induced parkinsonism, a Unified Parkinson's Disease Rating Scale (UPDRS) rest tremor score of 3 or greater for any limb, a Mini-Mental State Examination score of 25 or less, a history of stroke, the use of certain supplements, and substantial recent exposure to CoQ10. Of 696 participants screened, 78 were found to be ineligible, and 18 declined participation.

INTERVENTIONS

The remaining 600 participants were randomly assigned to receive placebo, 1200 mg/d of CoQ10, or 2400 mg/d of CoQ10; all participants received 1200 IU/d of vitamin E.

MAIN OUTCOMES AND MEASURES

Participants were observed for 16 months or until a disability requiring dopaminergic treatment. The prospectively defined primary outcome measure was the change in total UPDRS score (Parts I-III) from baseline to final visit. The study was powered to detect a 3-point difference between an active treatment and placebo.

RESULTS

The baseline characteristics of the participants were well balanced, the mean age was 62.5 years, 66% of participants were male, and the mean baseline total UPDRS score was 22.7. A total of 267 participants required treatment (94 received placebo, 87 received 1200 mg/d of CoQ10, and 86 received 2400 mg/d of CoQ10), and 65 participants (29 who received placebo, 19 who received 1200 mg/d of CoQ10, and 17 who received 2400 mg/d of CoQ10) withdrew prematurely. Treatments were well tolerated with no safety concerns. The study was terminated after a prespecified futility criterion was reached. At study termination, both active treatment groups showed slight adverse trends relative to placebo. Adjusted mean changes (worsening) in total UPDRS scores from baseline to final visit were 6.9 points (placebo), 7.5 points (1200 mg/d of CoQ10; P = .49 relative to placebo), and 8.0 points (2400 mg/d of CoQ10; P = .21 relative to placebo).

CONCLUSIONS AND RELEVANCE

Coenzyme Q10 was safe and well tolerated in this population, but showed no evidence of clinical benefit.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00740714.

Pipeline embolization device in aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The PED is an FDS designed for the treatment of intracranial aneurysms. Data regarding the use of this device in acute or subacute aSAH is limited to a few case reports or small series. We aimed to demonstrate the feasibility of using an FDS, the PED, for the treatment of ruptured intracranial aneurysms with challenging morphologies.

MATERIALS AND METHODS

We conducted a retrospective review of all known patients treated with the PED for aSAH at 4 institutions between June 2008 and January 2012. Pertinent clinical and radiologic information was submitted by individual centers for central collation. The decision to treat with the PED was made on a case-by-case basis by a multidisciplinary team under compassionate use.

RESULTS

Twenty patients (15 women; median age, 54.5 years; IQR, 8.0 years) were found. There were 8 blister, 8 dissecting or dysplastic, 2 saccular, and 2 giant aneurysms. Median time to treatment was 4 days (range, 1-90 days; IQR, 12.75 days) from rupture. Three patients had previous failed treatment. Procedure-related symptomatic morbidity and mortality were 15%, with 1 (5%) procedure-related death. Two patients died relative to medical complications, and 1 patient was lost to follow-up. Sixteen patients were available for follow-up, 81% had a GOS of 5, and 13% had a GOS of 4 attributed to a poorer initial clinical presentation. One patient died of urosepsis at 4 months. Occlusion rates were 75% and 94% at 6 months and 12 months, respectively. There were 3 delayed complications (1 silent perforator infarct, 2 moderate asymptomatic in-stent stenoses). No symptomatic delayed complications or rehemorrhages occurred.

CONCLUSIONS

The FDS may be a feasible treatment option in the acute or subacute setting of selected ruptured aneurysms, especially blister aneurysms. Ruptured giant aneurysms remain challenging for both surgical and endovascular techniques; at this stage, FDSs should be used with caution in this aneurysm subtype.

Canadian experience with the pipeline embolization device for repair of unruptured intracranial aneurysms

BACKGROUND AND PURPOSE

Flow-diverting stents, such as the PED, have emerged as a novel means of treating complex intracranial aneurysms. This retrospective analysis of the initial Canadian experience provides insight into technical challenges, clinical and radiographic outcomes, and complication rates after the use of flow-diverting stents for unruptured aneurysms.

MATERIALS AND METHODS

Cases were compiled from 7 Canadian centers between July 2008 and December 2010. Each center prospectively tracked their initial experience; these data were retrospectively updated and pooled for analysis.

RESULTS

During the defined study period, 97 cases of unruptured aneurysm were treated with the PED, with successful stent deployment in 94 cases. The overall complete or near-complete occlusion rate was 83%, with a median follow-up at 1.25 years (range 0.25-2.5 years). Progressive occlusion was witnessed over time, with complete or near-complete occlusion in 65% of aneurysms followed through 6 months, and 90% of aneurysms followed through 1 year. Multivariate analysis found previous aneurysm treatment and female sex predictive of persistent aneurysm filling. Most patients were stable or improved (88%), with the most favorable outcomes observed in patients with cavernous carotid aneurysms. The overall mortality rate was 6%. Postprocedural aneurysm hemorrhage occurred in 3 patients (3%), while ipsilateral distal territory hemorrhage was observed in 4 patients (3.4%).

CONCLUSIONS

Flow-diverting stents represent an important tool in the treatment of complex intracranial aneurysms. The relative efficacy and morbidity of this treatment must be considered in the context of available alternate interventions.

Delayed ipsilateral parenchymal hemorrhage following flow diversion for the treatment of anterior circulation aneurysms

BACKGROUND AND PURPOSE

The PED is a flow-diverting stent designed for the treatment of cerebral aneurysms. We report 4 cases of delayed ipsilateral IPH following the technically successful treatment of anterior circulation aneurysms with the PED.

MATERIALS AND METHODS

Clinical and imaging data from all patients undergoing aneurysm treatment with the PED at 2 institutions were analyzed to assess the incidence of delayed IPH after treatment with the PED.

RESULTS

A total of 66 patients (47 anterior circulation) with cerebral aneurysms underwent treatment with a PED between January 2008 and November 2010. Four patients experienced delayed periprocedural IPH, all after the treatment of anterior circulation aneurysms (8.5%, 4/47). The aneurysm size ranged from 5 to 21 mm. All IPHs occurred within the cerebral hemisphere, ipsilateral to the treated aneurysm, and were anatomically remote from the treated aneurysms. All procedures were uncomplicated, and patients emerged from general anesthesia at neurologic baseline. The hemorrhages became clinically evident between 1 and 6 days after the procedure. Two patients had unfavorable outcomes (mRS scores, 4 and 6).

CONCLUSIONS

Delayed IPH may occur after the treatment of anterior circulation aneurysms with flow diverters. This complication does not seem to be restricted to a specific aneurysm subtype and does not seem to be related to an intraprocedural complication or solely attributable to DAT.

Vascular wall imaging of vulnerable atherosclerotic carotid plaques: current state of the art and potential future of endovascular optical coherence tomography

As stroke is one of the leading causes of death and long-term morbidity worldwide, the research community has studied cardiac embolic sources, as well as vessel wall pathologies. For the latter, attention has been focused on defining morphologic tissue features associated with catastrophic events stemming from the carotid artery. Multiple noninvasive imaging modalities are currently being used to image and classify carotid atherosclerotic plaques, such as MR imaging, CT, and sonography, in an effort to provide clinically relevant predictive metrics for use in patient risk stratification and to define appropriate treatment options. This article compares and contrasts these existing clinical imaging modalities along with discussion of a new endovascular technique originally developed for cardiology, OCT, with which 3D comprehensive high-resolution images of the arterial wall can be acquired.

Giant submental lipoma: Case report and review of the literature

Lipomas may be located in all parts of the body and may be confused clinically with other soft tissue masses. They infrequently occur in the head and neck. A large neck mass (greater than 10 cm) with a rapid growth rate should raise concerns about a possible malignancy. Failure to distinguish a liposarcoma from a lipoma may represent a medicolegal pitfall. Surgical excision of a lipoma is often used as the definitive treatment modality, and alternative treatments described for lipomas range from liposuction to steroid injections. In the present study, a 60-year-old man who presented with a rapidly enlarging submental mass is described. A 15 cm x 12 cm mass was successfully removed. The surgery produced excellent cosmetic results and no functional impairment. An integrated review of the literature regarding etiology, epidemiology, diagnostic and treatment modalities of submental lipomas follows.

International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia

BACKGROUND

HHT is an autosomal dominant disease with an estimated prevalence of at least 1/5000 which can frequently be complicated by the presence of clinically significant arteriovenous malformations in the brain, lung, gastrointestinal tract and liver. HHT is under-diagnosed and families may be unaware of the available screening and treatment, leading to unnecessary stroke and life-threatening hemorrhage in children and adults.

OBJECTIVE

The goal of this international HHT guidelines process was to develop evidence-informed consensus guidelines regarding the diagnosis of HHT and the prevention of HHT-related complications and treatment of symptomatic disease.

METHODS

The overall guidelines process was developed using the AGREE framework, using a systematic search strategy and literature retrieval with incorporation of expert evidence in a structured consensus process where published literature was lacking. The Guidelines Working Group included experts (clinical and genetic) from eleven countries, in all aspects of HHT, guidelines methodologists, health care workers, health care administrators, HHT clinic staff, medical trainees, patient advocacy representatives and patients with HHT. The Working Group determined clinically relevant questions during the pre-conference process. The literature search was conducted using the OVID MEDLINE database, from 1966 to October 2006. The Working Group subsequently convened at the Guidelines Conference to partake in a structured consensus process using the evidence tables generated from the systematic searches.

RESULTS

The outcome of the conference was the generation of 33 recommendations for the diagnosis and management of HHT, with at least 80% agreement amongst the expert panel for 30 of the 33 recommendations.

ICONE: An International Consortium of Neuro Endovascular Centres

SUMMARY

The proliferation of new endovascular devices and therapeutic strategies calls for a prudentand rational evaluation of their clinical benefit. This evaluation must be done in an effective manner and in collaboration with industry. Such research initiative requires organisation a land methodological support to survive and thrive in a competitive environment. We propose the formation of an international consortium, an academic alliance committed to the pursuit of effective neurovascular therapies. Such a consortium would be dedicated to the designand execution of basic science, device developmentand clinical trials. The Consortium is owned and operated by its members. Members are international leaders in neurointerventional research and clinical practice. The Consortium brings competency, knowledge, and expertise to industry as well as to its membership across aspectrum of research initiatives such as: expedited review of clinical trials, protocol development, surveys and systematic reviews; laboratory expertise and support for research design and grant applications to public agencies. Once objectives and protocols are approved, the Consortium provides a stable network of centers capable of timely realization of clinical trials or pre clinical investigations in an optimal environment. The Consortium is a non-profit organization. The potential revenue generated from clientsponsored financial agreements will be redirected to the academic and research objectives of the organization. The Consortium wishes to work inconcert with industry, to support emerging trends in neurovascular therapeutic development. The Consortium is a realistic endeavour optimally structured to promote excellence through scientific appraisal of our treatments, and to accelerate technical progress while maximizing patients' safety and welfare.

The use of an innovative device for wound closure after upper extremity fasciotomy

INTRODUCTION

The purpose of this paper is to evaluate the Silver Bullet Wound Closure Device (SBWCD, Boehringer Laboratories, Norristown, PA), a new device for delayed primary closure of fasciotomy wounds.

MATERIALS AND METHODS

A retrospective review was performed over a period of 36 months of all patients with an upper extremity fasciotomy that could not be closed primarily. Cases that underwent fasciotomy closure with the SBWCD were separated from the patients that had a split thickness skin graft (STSG).

RESULTS

Seven patients had their wound closed with the SBWCD within 10 days (mean of 7.4 days). The seven patients that underwent STSG had their wound closed in an average of 8.4 days. The average number of days between the day of the fasciotomy incision and the date of the placement of the SBWCD was 1.9 days. STSGs were placed on the fasciotomy wounds on an average of 10.3 days after the date of the fasciotomy incision. We found that the SBWCD allowed for starting to approximate the edges of the fasciotomy wound at an earlier time when compare to STSG (2.1 vs 10.3 days).

CONCLUSIONS

We feel that the SBWCD as a one-stage procedure provides a consistent and efficacious way to manage upper extremity fasciotomy wounds while minimizing the morbidity associated with STSG. Elimination of a second-stage procedure reduces hospital costs. Our findings may help to inform surgeons about an available alternative when an upper extremity fasciotomy wound is not amenable to primary closure.

Endovascular treatment of intracranial aneurysms with matrix coils: immediate posttreatment results, clinical outcome and follow-up

INTRODUCTION

Endovascular aneurysm repair with coils has become a safe and effective alternative to surgical clipping. Efforts have been made to create coils that will facilitate aneurysm healing and reduce recurrence. The purpose of this study was to review the safety and durability of our aneurysm treatment using Matrix coils.

METHODS

A total of 39 aneurysms in 38 patients, aged 30 to 77 years, were treated using Matrix coils in 42 procedures. Two procedures were unsuccessful, and 12 were done using only Matrix coils. Aneurysm volume, packing density and percentage length of Matrix coils were calculated. The treatment results, procedural complication rate and clinical outcome were analyzed. Follow-up examinations were available for 34 procedures with a mean follow-up of 4.9 months (maximum 13.5 months).

RESULTS

Angiographic results were similar to those following the use of platinum coils, with complete occlusion or a residual neck in 82.5% of procedures. Six procedures (14%) were complicated with platelet aggregation. Recanalization occurred in 32% of the patients. Nine patients (26%) had major recanalization and were retreated. One patient had a re-bleed 5 months after the treatment resulting in severe disability. The mean packing density of 39.2% in the recanalized aneurysms was similar to that in the nonrecanalized group.

CONCLUSION

In our series, treatment with Matrix coils had a complication rate similar to that reported with platinum coils. However, we had a higher percentage of major recanalizations requiring retreatment. We believe that the absorption of the polymer contributes to the failure of formation of a stable scar within the aneurysm.

Increased Prevalence of Community-Acquired Methicillin-Resistant Staphylococcus aureus in Hand Infections at an Urban Medical Center

BACKGROUND

The purpose of this article is to report the increased incidence of community-acquired methicillin-resistant S. aureus in hand infections at an urban medical center.

METHODS

The authors performed a retrospective review of all patients with hand infections over a 21-month period, and all patients with culture-positive methicillin-resistant S. aureus were identified. Cases determined to be nosocomial were excluded. The study period was divided into three 7-month periods.

RESULTS

A total of 343 hand infections were treated over a 21-month period. Eighty-nine patients (26 percent) with culture positive methicillin-resistant S. aureus were identified; of these, 75 were determined to be community-acquired methicillin-resistant S. aureus patients. Statistical analysis was performed using the Fisher's exact test (p < 0.0001), the chi-square test for equal proportions, the Cochran-Armitage trend test, and two-way analysis of variance. The demographics of the patients were compared using two-way analysis of variance, and patients were found to be similar in all three time periods with respect to mean age and sex. The incidence of community-acquired methicillin-resistant S. aureus increased to 40 percent during the last 7-month period compared with 14 percent during the first two periods. Overall, the incidence of methicillin-resistant S. aureus increased to 47 percent during the last 7 months compared with 16 percent and 17 percent in the first two 7-month periods, respectively. Based on their treatment approach and literature review, the authors have developed an algorithm to treat community-acquired methicillin-resistant S. aureus hand infections.

CONCLUSIONS

The authors' findings at Temple University Hospital may help to alert health care providers to take necessary steps to control the spread of methicillin-resistant S. aureus in the community and in the inpatient setting. Cultures should be carefully followed and infections should be treated with appropriate antibiotics.

Avoiding Free Nipple Grafts During Reduction Mammaplasty in Patients With Gigantomastia

Excessive breast hypertrophy or gigantomastia (>2000 g excision of tissue per breast) has traditionally been approached with breast amputation and free nipple grafting during reduction mammaplasty procedures. Disadvantages of free nipple grafts include loss of sensation, poor projection, uneven nipple-areolar complex pigmentation, and loss of lactation. We report our experiences utilizing the inferior pedicle technique of reduction mammaplasty with successful preservation of the nipple-areola complex for patients with gigantomastia. Between 2001 and 2003, 15 patients (ages 19--45) were identified with gigantomastia through review of pathology and operative reports. The inferior pedicle technique was performed in all cases by the attending staff assisted by plastic surgery residents. Patients were followed regularly from 1 week up to 1 year postoperatively. All patients reported relief from the physical sequelae of breast hypertrophy. One patient experienced bilateral partial nipple desquamation; she maintained sensation throughout and healed well with moist dressings. Otherwise, there were no complications and all patients achieved satisfactory esthetic outcomes. Our results suggest that inferior pedicle technique can be successfully performed in patients with gigantomastia. Breast amputation with free nipple grafting need not be considered standard practice for this patient population. Maintaining a wider pedicle base and meticulous intraoperative handling of the pedicle may contribute to the increased viability of the nipple-areolar complex during these cases.

Recalcitrant Chest Wall Aspergillus Fumigatus Osteomyelitis After Coronary Artery Bypass Grafting: Successful Radical Surgical and Medical Management

This report describes a 62-year-old male diabetic patient with persistent chest wall osteomyelitis that developed after repeat coronary artery bypass grafting. The chronic infection was localized to the right anterior chest wall and refractory to medical and surgical treatment including long-term antiobiotics, five separate intraoperative debridements, and reconstruction with vascularized omentum over a two-year period at outside institutions. Aggressive surgical debridement with flap reconstruction resulted in definitive management. The organism isolated from multiple intraoperative bone, cartilage, and tissue cultures yielded Aspergillus fumigatus; therapy with itraconazole was utilized for 6 months. Surgical management of osteomyelitis and costochondritis is reviewed accompanied by a literature review on this uncommon cause of chronic chest wall infection.

Frontal sinus obliteration with beta-tricalcium phosphate

Autogenous materials are considered the gold standard when indicated for frontal sinus obliteration; however, alloplastic alternatives obviate the need for a second surgical site, eliminate donor site morbidity, and reduce operating room time. A variety of different alloplastic materials have been used for this purpose, but no report to date has described the use of pure beta -tricalcium phosphate synthetic bone. This case report describes the technique and successful use of this product for frontal sinus obliteration in a severely comminuted anterior table and nasofrontal duct injury. The product warrants consideration as a viable alternative to standard autogenous and alloplastic substrates for frontal sinus obliteration.

Composite Plate and Wire Fixation for Complicated Sternal Closure

Many techniques have been described to achieve closure of complicated median sternotomy wounds. The standard method of closure uses stainless steel wiring of the sternal halves; however, in complicated sternal closures, sternal cut-through and wire failure can occur. Recent literature advocates the use of fixation plates that achieve bony union, with plating across the median sternal osteotomy site as a singular method. We describe a technique of composite closure using titanium fixation plates to buttress the sternum in combination with circumferential stainless steel wires. This composite technique has been used in 6 patients with complicated sternal closures. Successful wound closure without complication was achieved in all cases. The technique and the clinical series with an illustrative example are presented. The use of plate and wire fixation represents an alternate method to conventional techniques to achieve sternal closure, stability, and uncomplicated wound healing in these difficult-to-manage cases.

Effect of ruminal protein degradability on growth and N metabolism in growing beef steers

The objective of two experiments was to correlate plasma levels of urea N (PUN) and the percentage of urine N in the form of urea (UUN) to weight gain in response to different dietary protein regimens for growing Angus steers. In Exp. 1, 60 steers (302 kg BW) were assigned to various levels of dietary N (control plus supplemental N to provide from 100 to 400 g more crude protein daily) within two sources of supplemental N (soybean meal [SBM] or a mixture of two parts corn gluten meal:one part blood meal [CGM:BM]). In Exp. 2, 27 steers (229 kg BW) were fed two levels of SBM, and half of the steers received growth-promoting implants. Steers were housed in groups of 12 and fed individually for 84 d in both experiments. Corn silage was fed at a restricted rate to minimize orts. Jugular blood and urine samples were collected during the experiments. In Exp. 1, maximal ADG of steers fed SBM (1.0 kg) was reached with 671 g/d total crude protein, or 531 g/d metabolizable protein. Maximal ADG of steers fed CGM:BM (0.91 kg) was reached with 589 g/d total crude protein, or 539 g/d metabolizable protein. The DMI was higher (P < 0.07) for steers fed SBM (6.37 kg/d) than for steers fed CGM:BM (6.14 kg/d). Increasing ruminal escape protein from 36% (SBM) to 65% (CGM:BM) of CP decreased (P < 0.05) endogenous production of urea, as evidenced by lower concentrations of urea in blood and lower UUN. In Exp. 2, increasing supplemental protein from 100 to 200 g/d increased (P < 0.05) ADG and PUN. Implants lowered (P < 0.05) UUN, particularly at the higher level of supplemental protein. Protein supplementation of growing steers can be managed to maintain acceptable ADG yet decrease excretion of urea in the urine.

Enhancement of graft survival and sensorimotor behavioral recovery in rats undergoing transplantation with dopaminergic cells exposed to glial cell line-derived neurotrophic factor

OBJECT

The goal of this study was to investigate the ability of fetal dopaminergic neurons to improve complex sensorimotor behavior.

METHODS

The authors obtained ventral mesencephalic tissue from 14-day-old rat fetuses. The cells were exposed to glial cell line-derived neurotrophic factor (GDNF) prior to transplantation into rats with unilateral 6-hydroxydopamine lesions of the dopaminergic nigrostriatal pathway. Animals that received 400,000 cells exposed to GDNF demonstrated significant improvement in contralateral forelimb function and showed improvement in rotational behavior faster than animals that received cells not exposed to GDNF. Increasing the number of implanted cells to 800,000 exposed to GDNF did not result in any additional improvement in functional recovery.

CONCLUSIONS

As neural grafting procedures in the nervous system evolve and genetically engineered cells or stem cells replace fetal tissue, crucial questions about cell number and trophic regulation will need to be addressed. This study demonstrates that grafting of 400,000 cells exposed to GDNF before transplantation has a beneficial effect in the restoration of complex sensorimotor behavior.

Neural transplantation in Parkinson's disease

Parkinson's disease is a neurodegenerative disorder that affects about 1% of Canadians between the ages of fifty and seventy. The medical management for these patients consists of drug therapy that is initially effective but has limited long term benefits and does not alter the progressive course of the disease. The recalcitrance of longstanding Parkinson's disease to medical management has prompted the use of alternative surgical therapies. Many neurosurgical procedures have been utilized in order to improve the disabling symptoms these patients harbour. Although most of the current procedures involve making destructive lesions within various basal ganglia nuclei, neural transplantation attempts to reconstitute the normal nigrostriatal pathway and restore striatal dopamine. The initial success of neural transplantation in the rodent and primate parkinsonian models has led to its clinical application in the treatment of parkinsonian patients. Currently, well over one hundred patients throughout the world have been grafted with fetal tissue in an effort to ameliorate their parkinsonian symptoms. Although the results of neural transplantation in clinical trials are promising, a number of issues need to be resolved before this technology can become a standard treatment option. This review focuses on the current status of neural transplantation in Parkinson's disease within the context of other surgical therapies in current use.

Isolated avulsion of the flexor digitorum superficialis tendon

Isolated, closed avulsion of the flexor digitorum superficialis tendon at its insertion is thought to be a rare diagnostic entity, with only six cases reported in the literature. However, we have diagnosed and treated 11 such cases, each presenting with a tender palmar mass and loss of active flexor digitorum superficialis function. Some patients had proximal interphalangeal joint contractures. Upon exploration, the retracted superficialis tendon was found to ensnare the profundus tendon at the level of the A1 pulley. Following tenolysis, flexor digitorum superficialis tendon excision, and in selected patients capsulotomies, each patient achieved good functional capacity.

Psychogenic habit cough: review and case reports

Psychogenic habit cough--a condition that can be debilitating if it extends over a period of years--has been described in both pediatric and adolescent populations, but not in adults. The authors review the cases of 4 adult patients with this condition, review the available pediatric/adolescent literature, and make suggestions for the direction of future research. In some cases, psychogenic habit cough in adults can be successfully treated with a combination of psychotherapy, relaxation therapy, and speech therapy.

High precision quantitative angiography

Statistical considerations on the precision in the determination of blood vessel dimensions from digitized cine angiographic images are described. The resolution requirements related to "point measurements" and segmental diameter curve evaluations are discussed. The error associated with inaccurate determination of the vessel's centerline is analyzed. The concepts have been implemented on a high-speed image analyzing system, which measures blood vessel diameters with advanced automation. The performance of the system was evaluated with blood vessel phantoms, ranging in diameter from 0.88 to 6.26 mm. For these phantoms the minimum measurable change in vessel dimension over 20-pixel (-1.1 mm) long segments ranged from 3.4 to 0.2 percent, respectively.

Computer reconstruction of luminal cross-sectional shape from multiple cineangiographic views

Knowledge of coronary luminal shape, in addition to diameter information as routinely obtained from a cineangiogram, may be useful in assessing lesions which deviate from circular symmetry. We have developed an image analysis system for automated tracking of luminal edges and measurement of diameter form cine frames digitized by a video camera/digitizer interfaced to a Vax 11/780 computer. Between vessel edges, cinedensitometric profiles across the vessel long axis are used to provide a rotationally invariant measure of relative luminal cross-sectional area. A maximum entropy iterative algorithm is used to reconstruct the lumen cross section from a set of projection data consisting of the cinedensitometric profiles from multiple radiographic views. Nonaxisymmetric model coronary lumena, such as a crescent shape and a double lumen simulating a coronary artery dissection, were filmed under cineradiographic conditions similar to clinical exposures. Radiographic views at 10 degrees increments about the model lumen long axis over 360 degrees were available for analysis. Graphic display of reconstructed model lumena indicate that as few as three to five radiographic views may be useful in reconstructing coronary luminal shape.