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Background: Many individuals will also experience psychological side effects after a stroke episode, such as symptoms of depression, anxiety (generalized anxiety disorder (GAD)), and/or specific phobias, considerably decreasing their quality of life (QOL)., Objective: This study aimed to evaluate the prevalence of depression, obstructive sleep apnea (OSA), and concurrent anxiety (DOCA) and their outcomes (morbidity, disability (All Patient Refined Diagnosis Related Group (APRDRG) - loss of function), and discharge disposition) among acute ischemic stroke (AIS) hospitalizations., Methods: A cross-sectional study used the National Inpatient Sample (NIS) from 2003-2017. Adults with hospitalizations with AIS were extracted, and DOCA was identified using ICD-9/10-CM codes. Weighted analysis using a chi-square test and mixed-effect multivariable survey logistic regression was used to assess the prevalence and role of DOCA in predicting outcomes., Results: Out of 5,690,773 AIS hospitalizations, 2.7%, 3.1%, and 4.4% had depression, OSA, and GAD, respectively. In AIS patients, females had a higher prevalence of depression (3.4% vs. 2.3%) and GAD (5.9% vs. 3.0%) and a quality of life lower prevalence of OSA (2.2% vs 4.4%) in comparison to males (p<0.0001). Caucasians had a higher prevalence of depression, OSA, and GAD in comparison to others (African Americans/Hispanics/Asians/Native Americans). Depressed patients had a higher prevalence of morbidity (9% vs. 8% vs 5% vs. 7%), disability (46% vs. 46% vs. 35% vs. 37%), transfer to non-home (69% vs. 58% vs. 61% vs. 63%) in comparison with OSA, GAD, and non-DOCA patients, respectively (p<0.0001). Depression was associated with a 40% higher chance of severe disability (aOR 1.40; 95% CI 1.38-41), morbidity (1.36; 1.33-1.38), and discharge to non-home (1.54; 1.52-1.56). OSA and GAD had higher odds of non-home discharge amongst post-AIS hospitalizations., Conclusion: DOCA is associated with poor outcomes among post-AIS patients. Prompt recognition by screening and timely management of DOCA may mitigate the adverse outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Patel et al.)

The era of metal-on-metal (MoM) total hip arthroplasty has left the orthopaedic community with valuable insights and lessons on periprosthetic tissue reactions to metallic debris. Various terms have been used to describe the tissue reactions. Sometimes the nomenclature can be confusing. We present a review of the concepts introduced by Willert and Semlitsch in 1977, along with further developments made in the understanding of periprosthetic tissue reactions to metallic debris. We propose that periprosthetic tissue reactions be thought of as (1) gross (metallosis, necrosis, cyst formation and pseudotumour); (2) histological (macrophage-dominated, lymphocyte-dominated or mixed); and (3) molecular (expression of inflammatory mediators and cytokines such as interleukin-6 and tumor necrosis factor-alpha). Taper corrosion and modularity are discussed, along with future research directions to elucidate the antigen-presenting pathways and material-specific biomarkers which may allow early detection and intervention in a patient with adverse periprosthetic tissue reactions to metal wear debris.

A 9-year-old girl with severe unilateral ocular surface disease due to limbal stem cell deficiency following chemical injury underwent autologous cultivated limbal epithelial transplantation (CLET) twice in her right eye that failed to improve the condition of the ocular surface. On both occasions, limbal biopsies were obtained from the unaffected left eye. Since further attempts at CLET were not considered to be safe, deep anterior lamellar keratoplasty (DALK) was performed instead. DALK was complicated by postoperative Descemet's membrane detachment, which was successfully treated. Two years post-DALK the patient had a clear graft, stable ocular surface and visual acuity of 20/80. The mechanism by which CLET allows a patient to repopulate the ocular surface is as yet unknown. This case highlights that although clinically little had changed following two failed CLET surgeries, some subclinical improvement must have taken place for a DALK to remain successful after 2 years.

Background: Acetylsalicylic acid (ASA) is used in the treatment of acute myocardial infarction (AMI) but is also a risk factor for peptic ulcer disease (PUD) bleeding., Objective: To determine the factors associated with continued ASA use in patients with AMI who develop PUD bleeding., Methods: AMI patients who developed PUD bleeding during the same hospitalization at two tertiary care hospitals in Edmonton, Alberta, between January 1999 and December 2006, were evaluated retrospectively. Multivariate analysis was used to determine predictors of the primary outcome of continued ASA use during PUD bleeding., Results: A total of 102 patients were analyzed. Thirty-eight patients (37%) were continued on ASA, while 64 (63%) had ASA discontinued during their hospitalization. On multivariate regression analysis, significant predictors of continued ASA use included lowrisk ulcer stigmata on endoscopy (OR 3.7; 95% CI 1.4 to 10.2; P=0.01) and AMI requiring coronary intervention (OR 8.2; 95% CI 2.1 to 32.1; P=0.002). The mean (+/- SD) blood transfusion requirement was 3.9+/-3.6 units. The 30-day rebleeding and mortality rates were 14% and 14%, respectively., Conclusions: The continued use of ASA during AMI and PUD bleeding was variable. However, patients with low-risk ulcers and those who received coronary intervention were more likely to have ASA continued during PUD bleeding. Further studies evaluating the gastrointestinal risk of immediate ASA use in AMI with acute PUD bleeding are required.

Background: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the preferred modality for the cytological diagnosis of various cancers. Onsite cytopathology interpretation is not available in most centres., Objective: To assess whether the the adequacy of tissue sampling assessed by an onsite cytotechnologist improves the diagnostic accuracy of EUS-FNA., Methods: The present study is a retrospective review of all patients undergoing solid mass EUS-FNA between September 2005 and August 2007. Patients in group I (September 2005 to August 2006) had cytology slides prepared by an endoscopy nurse. Patients in group II (September 2006 to August 2007) had cytology slides prepared, stained and assessed for adequacy of tissue sampling by a cytotechnologist in the endoscopy suite. The final cytopathological diagnosis (definitely positive, definitely negative or inconclusive) was compared between the two groups., Results: A total of 49 EUS-FNA procedures were performed in 47 patients in group I and 60 EUS-FNA procedures in 55 patients in group II. Pancreatic masses were the most common target site in both groups. The total number of needle passes was 105 in group I (mean 2.14 passes per patient; range one to five needle passes) and 158 in group II (mean 2.63 passes per patient; range one to four needle passes). The difference in the number of needle passes was not statistically significant between groups. The final diagnosis was definite in 53% in group I compared with 77% in group II (P=0.01). The percentage of inconclusive diagnoses was 47% in group I and 23% in group II (P=0.001)., Conclusion: Onsite cytotechnologist interpretation of adequacy of tissue sampling significantly improves the diagnostic yield of EUS-FNA. This appears to be independent of the total number of needle passes undertaken for tissue sampling.

Background: Endoscopic ultrasound (EUS) is accurate in diagnosing pancreatic neuroendocrine tumours (PNETs), but its impact on surgical management is unclear., Objective: To determine whether preoperative EUS findings altered the decision for, and extent of, surgery in patients with PNETs., Methods: A retrospective review of patients referred for EUS because of suspected PNETs was conducted. The diagnosis of PNETs was confirmed by EUS-guided fine needle aspiration cytology, where indicated, or by surgical histology. EUS findings were compared with computed tomography (CT) findings to determine whether there was an impact on the decision for surgical management., Results: Fourteen patients (10 women), with a mean age of 44 years, underwent EUS for suspected PNETs. PNETs were seen with CT in 10 of 13 patients (77%) and with EUS in 14 of 14 patients (100%). One obese patient could not fit into the CT scanner. This patient had five PNETs on EUS. Three patients with a normal CT scan were determined to have one or two PNETs on EUS. Three patients with one or two PNETs on CT were found to have five to eight PNETs on EUS. EUS altered the decision for possible surgical management in five of 14 patients (36%), either by identifying a PNET or by finding multiple and multifocal PNETs that were not visualized on CT scans., Conclusion: EUS is useful in the preoperative assessment of PNETs by providing information that significantly influences the decision for surgical intervention or changes the extent of the planned surgery.

Background: Various modalities including CT, positron emission tomography (PET), and EUS are being used for esophageal cancer staging., Objective: We compared results of locoregional staging by CT, PET, and EUS with histologic staging., Design: Retrospective chart review., Setting: Tertiary referral center., Patients and Interventions: Patients with esophageal cancer proven by endoscopy and biopsy underwent a CT scan of the chest and abdomen and a PET scan. Patients with no evidence of distant metastatic disease on CT and PET were referred for EUS for locoregional staging., Main Outcome Measurement: The tumor size (T) and lymph node (N) stage as determined by EUS were compared with surgical pathology or EUS-guided FNA cytology. The results of N staging with CT, PET, and EUS were compared with surgical pathology or EUS-FNA cytology., Results: Between May 2005 and April 2006, 29 patients (24 men, mean age 68 years) underwent EUS. EUS was successful in 25 of 29 patients (86%). There were no EUS-related complications. Eleven of 16 patients with available lymph node histologic study had confirmed metastasis. Nodal metastasis was correctly identified by CT in 6 of 11 patients, by PET in 4 of 11 patients, and by EUS in 10 of 11 patients. Overall accuracy for N staging was 69% for CT, 56% for PET, and 81% for EUS. Fifteen patients had confirmed T staging by surgical pathologic examination. The percentage of agreement for T staging between EUS and surgical pathology was 80% (12/15 patients)., Limitations: Single center, retrospective chart review., Conclusion: EUS is safe and accurate for tumor and node staging in esophageal cancer. The combination of CT plus EUS appears to be accurate for locoregional staging in esophageal cancer.