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Background: Anti-Program-Death-1 (PD-1) is a standard adjuvant therapy for patients with resected melanoma. We hypothesized that there are discrepancies in survival, recurrence pattern and toxicity to adjuvant PD-1 between different ethnicities and melanoma subtypes. Objective: We performed a multicenter cohort study incorporating 6 independent institutions in Australia, China, Japan, and the United States. The primary outcomes were recurrence free survival (RFS) and overall survival (OS). Secondary outcomes were disease recurrence patterns and toxicities. Results: In total 534 patients were included. East-Asian/Hispanic/African reported significantly poorer RFS/OS. Nonacral cutaneous or melanoma of unknown primary reported the best RFS/OS, followed by acral, and mucosal was the poorest. Within the nonacral cutaneous or melanoma of unknown primary subtypes, East-Asian/Hispanic/African reported significantly poorer RFS/OS than Caucasian. In the multivariate analysis incorporating ethnicity/melanoma-subtype/age/sex/stage/lactate dehydrogenase/BRAF (v-Raf murine sarcoma viral oncogene homolog B)-mutation/adjuvant radiotherapy, East-Asian/Hispanic/African had independently significantly poorer outcomes (RFS: HR, 1.71; 95% CI, 1.19-2.44 and OS: HR, 2.34; 95% CI, 1.39-3.95), as was mucosal subtype (RFS: HR, 3.25; 95% CI, 2.04-5.17 and OS: HR, 3.20; 95% CI, 1.68-6.08). Mucosal melanoma was an independent risk factor for distant metastasis, especially liver metastasis. East-Asian/Hispanic/African had significantly lower incidence of gastrointestinal/musculoskeletal/respiratory/other-rare-type-toxicities; but higher incidences of liver toxicities. Limitations: A retrospective study. Conclusions: Ethnicity and melanoma subtype are associated with survival and recurrence pattern in melanoma patients treated with adjuvant anti-PD-1. Toxicity profile differs by ethnicity and may require a precision toxicity surveillance strategy.

Background: Lung nodule incidence is increasing. Many nodules require biopsy to discriminate between benign and malignant causes. The gold standard for minimally invasive biopsy, CT scan-guided transthoracic needle biopsy (CT-TTNB), has not been compared directly with navigational bronchoscopy, a method that recently has seen rapid technological innovation and is associated with improving diagnostic yield and lower complication rates. Current estimates of the diagnostic usefulness of both methods are based largely on noncomparative data with significant risk for selection, referral, and publication biases. Research Question: Is contemporary navigational bronchoscopy noninferior to CT scan-guided transthoracic needle biopsy for the diagnosis of indeterminate pulmonary nodules? Study Design and Methods: Navigation Endoscopy to Reach Indeterminate Lung Nodules vs Transthoracic Needle Aspiration, a Randomized Controlled Study, is a multicenter, 1:1 randomized, parallel-group trial designed to ascertain whether electromagnetic navigational bronchoscopy with integrated digital tomosynthesis is noninferior to CT-TTNB for the diagnosis of peripheral lung nodules 10 to 30 mm in diameter with before testing probability of malignancy of at least 10%. The primary end point is diagnostic accuracy through 12 months of follow-up. Secondary end points include diagnostic yield, complication rate, procedure duration, need for additional invasive diagnostic procedures, and radiation exposure. Results: This article describes the protocol and rationale for the Navigation Endoscopy to Reach Indeterminate Lung Nodules vs Transthoracic Needle Aspiration, a Randomized Controlled Study, designed to answer the study question. Interpretation: The results of this rigorously designed trial will provide high-quality data regarding the management of lung nodules, a common clinical entity that often represents the earliest and most treatable stage of lung cancer. Several design challenges are described. Notably, all nodules are reviewed centrally by an independent interventional pulmonology and radiology adjudication panel relying on prespecified exclusions to ensure enrolled nodules are amenable to sampling by both methods while protecting against selection bias favoring either method. Conservative diagnostic yield and accuracy definitions with prespecified criteria for what nonmalignant findings may be considered diagnostic were chosen to avoid inflation of estimates of diagnostic usefulness. Trial Registry: ClinicalTrials.gov; No.: NCT04250194; URL: www.clinicaltrials.gov

ABSTRACT: Background: Traumatic thoracolumbar fracture fixation without neurological injury can be performed using the traditional open, mini-open Wiltse, and percutaneous approaches. This systematic review and meta-analysis aims to compare perioperative outcomes between these approaches. Methods: PubMed, Web of Science, Scopus, Embase, and the Cochrane Library were searched for all relevant observational comparative studies. Results: 5 randomized trials and 22 comparative cohort studies were included. Compared to the traditional open approach (n=959), the Wiltse approach (n=410) was associated with significantly lower operative time, intraoperative estimated blood loss (EBL), and length of stay (LOS). There was no significant difference between the two in terms of postoperative visual analog scale (VAS) and Cobb angle. Compared to the percutaneous approach (n=980), the Wiltse approach was associated with shorter operative and fluoroscopy time, as well as significantly improved Cobb and vertebral body angles. The percutaneous approach was associated with improved vertebral body height. There was no significant difference between the two for blood loss, postoperative VAS, or LOS. Compared to the traditional open approach, the percutaneous approach was associated with shorter operative time, lower EBL, shorter LOS and better postoperative VAS and Oswestry Disability Index. There was no difference between the two in postoperative Cobb angle, vertebral angle, or vertebral body height. Overall study heterogeneity was high. Conclusions: Utilization of minimally invasive surgical approaches holds great promise for lowering patient morbidity and optimizing care. A prospective trial is needed to assess outcomes and guide surgical decision making.

Tenosynovial giant cell tumor (TGCT) occurs in both diffuse and localized forms. While diffuse TGCT is an uncommon but well-described complication after total knee arthroplasty (TKA), localized TGCT has only once been previously described as a postoperative complication after TKA. We report on the diagnosis and management of a patient who developed postoperative localized TGCT after routine TKA and underwent uncomplicated removal. Postoperatively the patient noted a resolution of pain and mechanical symptoms. Early consideration of this rare occurrence after TKA can prevent significant pain and disability due to delayed diagnosis.

Chronic low back pain (CLBP) is a debilitating, painful, and costly condition. Implantable neuromuscular electrical stimulation targeting the multifidus musculature is growing as a non-pharmacologic option for patients with recalcitrant nociceptive mechanical CLBP who have failed conservative treatments (including medications and physical therapy) and for whom surgery is not indicated. Properly selecting patients who meet specific criteria (based on historical results from randomized controlled trials), who diligently adhere to implant usage and precisely implement neuromuscular rehabilitation, improve success of significant functional recovery, as well as pain medication reductions. Patients with nociceptive mechanical CLBP who underwent implanted multifidus neurostimulation have been treated by physicians and rehabilitation specialists who have honed their experience working with multifidus neurostimulation. They have collaborated on consensus and evidence-driven guidelines to improve quality outcomes and to assist providers when encountering patients with this device. Physicians and physical therapists together provide precision patient-centric medical management with quality neuromuscular rehabilitation to encourage patients to be experts of both their implants and quality spine motion to help override long-standing multifidus dysfunction related to their CLBP.

Background: Majocchi's granuloma (MG) is an uncommon deep fungal folliculitis predominantly caused by dermatophytes. Given the rarity of this condition, available data regarding predisposing comorbidities/risk factors, clinical characteristics, offending microbiologic pathogens, diagnostics, pathologic findings, and treatment approaches has been inferred from historical cases. Objectives: To review our institutional experience with MG. Methods: We retrospectively analyzed a multicenter cohort of adult patients diagnosed with MG between 1992 and 2022. Results: We analyzed 147 patients with MG, 105 of which were male with a median age of 55.6 years. Immunosuppressant and topical corticosteroid use were common prior to development of MG. Dermatologic lesions and their sites of involvement did not differ based on the immune status of patients. Trichophyton rubrum was the most common causative pathogen of MG, in addition to other dermatophytes. Treatment duration for all prescribed agents was median 31.5 days with oral terbinafine being the most frequently utilized agent. Clinical resolution was achieved in 96.6% of cases. Limitations: Retrospective, nonrandomized study. Conclusions: Although rare and clinically variable in presentation, diagnosis of MG often requires histopathologic confirmation to subsequently direct prolonged treatment with systemic antifungal therapy for mycological cure.

Background: The Single-Incision Power Optimizing Cost-Effective Repair (SPOC) method reattaches the distal biceps tendon to its original posterior anatomic footprint and utilizes the anterior cortex of the supinated radius for fixation. The purpose of the study was to define the long-term complications and durability of the SPOC method. Methods: Two hundred and eighteen patients underwent the SPOC repair of distal biceps ruptures from 2008 to 2020, with 185 having at least 1-year follow-up data. The average follow-up was 50.1 months. Information regarding smoking, body mass index, interval between injury and surgery, peripheral nerve injury, heterotopic ossification, vascular injury, re-rupture, chronic regional pain syndrome, fracture of the radius, loss of motion, pain with use, and deformity were acquired. Results: No complication occurred beyond the third postoperative month. No patient complained of severe lateral antebrachial cutaneous nerve-related symptoms. Major complications exclusive of re-rupture occurred include 1 case of heterotopic ossification and 1 deep infection. Major complications with re-ruptures occurred in 9 patients (4.8%). Seven of the re-ruptures (78%) were associated with an unexpected forceful contraction within the first 4 weeks postop. All complications aside from 1 minor complication occurred in the chronic group. Long term follow-up revealed no re-ruptures and high satisfaction rate with return of strength, motion, and biceps profile. Conclusion: The safety profile of the SPOC repair is consistent with those of other published repairs. Major complications were associated with prolonged intervals between injury and reconstruction. Re-ruptures were associated with worker’s compensation status and patient noncompliance with postoperative protocols.

Revision surgery is paramount to cure chronic prosthetic joint infections because these infections are associated with biofilms on prosthetics that conventional antibiotics cannot eradicate. However, there is a paucity of research on where in vivo biofilms are located on infected prosthetics. Consequently, the objective of this pilot study was to address this gap in knowledge by staining 5 chronically infected prosthetics, that were removed at the time of revision surgery, with methylene blue. Scanning electron microscopic images were then taken of the methylene blue–stained areas to visualize biofilms. The findings show that all chronically infected prosthetics had biofilms located on the bone–prosthetic interface, yet only 2 had biofilms also located on the prosthetic interface exposed to synovial fluid. Subsequently, this pilot study provides a pathophysiological understanding of why the current treatment paradigm for chronic periprosthetic joint infection requires a revision surgery and not debridement and an implant retention surgery.

Purpose: To develop a machine learning tool capable of differentiating eyes of subjects with normal cognition from those with mild cognitive impairment (MCI) using OCT and OCT angiography (OCTA). Design: Evaluation of a diagnostic technology. Participants: Subjects with normal cognition were compared to subjects with MCI. Methods: A multimodal convolutional neural network (CNN) was built to predict likelihood of MCI from ganglion cell-inner plexiform layer (GC-IPL) thickness maps, OCTA images, and quantitative data including patient characteristics. Main Outcome Measures: Area under the receiver operating characteristic curve (AUC) and summaries of the confusion matrix (sensitivity and specificity) were used as performance metrics for the prediction outputs of the CNN. Results: Images from 236 eyes of 129 cognitively normal subjects and 154 eyes of 80 MCI subjects were used for training, validating, and testing the CNN. When applied to the independent test set using inputs including GC-IPL thickness maps, OCTA images, and quantitative OCT and OCTA data, the AUC value for the CNN was 0.809 (95% confidence interval [CI]: 0.681–0.937). This model achieved a sensitivity of 79% and specificity of 83%. The AUC value for GC-IPL thickness maps alone was 0.681 (95% CI: 0.529–0.832), for OCTA images alone was 0.625 (95% CI: 0.466–0.784) and for both GC-IPL maps and OCTA images was 0.693 (95% CI: 0.543–0.843). Models using quantitative data alone were also tested, with a model using quantitative data derived from images, 0.960 (95% CI: 0.902–1.00), outperforming a model using demographic data alone, 0.580 (95% CI: 0.417–0.742). Conclusions: This novel CNN was able to identify an MCI diagnosis using an independent test set comprised of OCT and OCTA images and quantitative data. The GC-IPL thickness maps provided more useful decision support than the OCTA images. The addition of quantitative data inputs also provided significant decision support to the CNN to identify individuals with MCI. Quantitative imaging metrics provided superior decision support than demographic data. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Purpose: The Retinal Ganglion Cell (RGC) Repopulation, Stem Cell Transplantation, and Optic Nerve Regeneration (RReSTORe) consortium was founded in 2021 to help address the numerous scientific and clinical obstacles that impede development of vision-restorative treatments for patients with optic neuropathies. The goals of the RReSTORe consortium are: (1) to define and prioritize the most critical challenges and questions related to RGC regeneration; (2) to brainstorm innovative tools and experimental approaches to meet these challenges; and (3) to foster opportunities for collaborative scientific research among diverse investigators. Design and Participants: The RReSTORe consortium currently includes > 220 members spanning all career stages worldwide and is directed by an organizing committee comprised of 15 leading scientists and physician-scientists of diverse backgrounds. Methods: Herein, we describe the structure and organization of the RReSTORe consortium, its activities to date, and the perceived impact that the consortium has had on the field based on a survey of participants. Results: In addition to helping propel the field of regenerative medicine as applied to optic neuropathies, the RReSTORe consortium serves as a framework for developing large collaborative groups aimed at tackling audacious goals that may be expanded beyond ophthalmology and vision science. Conclusions: The development of innovative interventions capable of restoring vision for patients suffering from optic neuropathy would be transformative for the ophthalmology field, and may set the stage for functional restoration in other central nervous system disorders. By coordinating large-scale, international collaborations among scientists with diverse and complementary expertise, we are confident that the RReSTORe consortium will help to accelerate the field toward clinical translation. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Objective: To describe the clinical and radiographic findings in a large cohort of patients with positive cultures for Nocardia emphasizing the differences between invasive disease and colonization. Patients and Methods: We conducted a single-center, retrospective cohort study of 133 patients with a positive Nocardia isolate between August 1, 1998, and November 30, 2018, and a computed tomography (CT) of the chest within 30 days before or after the bacteria isolation date. Results: Patients with colonization were older (71 vs 65 years; P=.004), frequently with chronic obstructive pulmonary disease (56.8% vs 16.9%; P

Background: Given the increased attention to functional improvement in spine surgery as it relates to activities of daily living and cost, it is critical to fully understand the health care economic impact of enabling technologies. The use of intraoperative neuromonitoring (IOM) during spine surgery has long been controversial. Questions pertaining to utility, medico-legal considerations, and cost-effectiveness continue to be unresolved. The purpose of this study is to determine the cost-effectiveness by assessing quality-of-life due to adverse events averted, decreased postoperative pain, decreased revision rates, and improved patient reported outcomes (PROs). Methods: The study patient population was extracted from a large multicenter database collected by a single, national IOM provider. Over 50,000 patient charts were abstracted and included in this analysis. The analysis was conducted in accordance with the second panel on cost-effectiveness health and medicine. Health-related utility was derived from questionnaire answers and expressed in quality-adjusted life years (QALYs). Both cost and QALY outcomes were discounted at a yearly rate of 3% to reflect their present value. Cost-effectiveness was calculated as the incremental cost-effectiveness ratio (ICER) for IOM. A value under the commonly accepted United States-based willingness-to-pay (WTP) threshold of $100,000 per QALY was considered cost-effective. Scenario (including litigation), probabilistic (PSA), and threshold sensitivity analyses were conducted to determine model discrimination and calibration. Results: The primary time horizon used to estimate cost and health utility was 2-years following index surgery. On average, index surgery for patients with IOM costs are approximately $1,547 greater than non-IOM cases. The base case assumed an inpatient Medicare population however multiple outpatient and payer scenarios were assessed in the sensitivity analysis. From a health system perspective IOM is cost-effective, yielding better utilities but at a higher cost than the non-IOM strategy (ICER $60,734 per QALY). From a societal perspective the IOM strategy was dominant, suggesting that better outcomes were achieved at less cost. Except for an entirely privately insured population, alternative scenarios such as, outpatient and a 50:50 Medicare/privately insured population sample also demonstrated cost-effectiveness. Notably, IOM benefits were unable to overcome the sheer costs associated many litigation scenarios, but the data was severely limited. In the 5,000 iteration PSA, at a WTP of $100,000, 74% of simulations using IOM were cost-effective. Conclusions: The use of IOM in spine surgery is cost-effective in most scenarios examined. In the emerging and rapidly expanding field of value-based medicine, there will be an increased demand for these analyses, ensuring surgeons are empowered to make the best, most sustainable solutions for their patients and the health care system.

Purpose: To assess the intrasession repeatability of macular OCT angiography (OCTA) parameters in Alzheimer's disease (AD), mild cognitive impairment (MCI), Parkinson's disease (PD), and normal cognition (NC). Design: Cross sectional study. Subjects: Patients with a clinical diagnosis of AD, PD, MCI, or NC were imaged. Images with poor quality and of those with diabetes mellitus, glaucoma, or vitreoretinal disease were excluded from analysis. Methods, Intervention or Testing: All participants were imaged using the Zeiss Cirrus HD-5000 with AngioPlex (Carl Zeiss Meditec, Software Version 11.0.0.29946) and repeat OCTA images were obtained for both eyes. Perfusion density (PFD), vessel density (VD), and Foveal avascular zone (FAZ) area were measured from 3 × 3 mm and 6 × 6 mm OCTA images centered on the fovea using an ETDRS grid overlay. Main Outcome Measures: Intraclass correlation coefficients were used to quantify repeatability of PFD, VD, and FAZ area measurements obtained from imaging. Results: 3 × 3 mm scans of 22 AD, 40 MCI, 21 PD, and 26 NC participants and 6 × 6 mm scans of 29 AD, 44 MCI, 29 PD, and 30 NC participants were analyzed. Repeatability values ranged from 0.64 (0.49–0.82) for 6 × 6 mm PFD in AD participants to 0.87 (0.67–0.92) for 3 × 3 mm PFD in AD participants. No significant differences were observed in repeatability between NC participants and those with neurodegenerative disease. Conclusions: Overall, similar OCTA repeatability was observed between NC participants and those with neurodegeneration. Regardless of diagnostic group, macular OCTA metrics demonstrated moderate to good repeatability. Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Total elbow arthroplasty (TEA) has become a well-accepted treatment option for many pathologies of the elbow joint. Its use in distal humerus fractures in elderly patients has become increasingly popular and has good clinical results. However, with the aging population and the increasing number of TEAs performed, so comes the potential for an increasing number of revision TEA cases. Revision TEA can be extremely challenging. In addition to the technical difficulties of safe exposure and implant removal, reimplantation of a cemented humeral component with loss of bone stock can be a challenging step in this procedure. The purpose of this article was to describe a novel technique to address aseptic loosening of the humeral stem and loss of humeral bone stock with revision of the humeral component using a long-stemmed cemented implant and intramedullary allograft fibular strut bone grafting.

Patients with type B aortic dissection (TBAD) often present as an emergency. Operative repair of TBAD can be indicated for selected patients in the setting of hemodynamic instability or rupture. Thoracic endovascular aortic repair of TBAD has achieved significant popularity. Variant aortic arch anatomy can present a significant clinical challenge in patients with an inadequate proximal landing zone for thoracic endovascular aortic repair. A three-stage, hybrid aortic arch debranching and endovascular repair of a ruptured TBAD in a patient with a bicarotid trunk and an aberrant right subclavian artery was successfully performed using a unique technical approach.

Myositis ossificans is a pathologic process of ossification in soft tissues. The breast is an exceptionally rare location for myositis ossificans with less than 5 cases documented in the English literature. We present a case of a 66-year-old woman with myositis ossificans of the left breast and no known initiating trauma. The significance of the progression of clinical and radiological findings are discussed in detail. This case shows the importance of radiology for identifying unique pathology as well as close radiological follow up.

BACKGROUND: Preeclampsia affects between 2% and 5% of pregnant people in North America. First-trimester preeclampsia screening based on the Fetal Medicine Foundation risk calculation algorithm combined with treatment of high-risk patients with aspirin effectively reduces the incidence of preterm preeclampsia more than the currently used risk factor–based screening. However, the impact of such screening on patient satisfaction and maternal anxiety is unknown. OBJECTIVE: This study aimed to assess the impact of first-trimester prediction and prevention of preterm preeclampsia on patient satisfaction and anxiety. STUDY DESIGN: Consenting pregnant patients participating in a local first-trimester (11–13+6 weeks) preterm preeclampsia screening and prevention implementation study1 were contacted 6 weeks postpartum to complete an online patient satisfaction survey, designed to assess their satisfaction with the screening program and their levels of trait anxiety (using an abbreviated version of the State-Trait Anxiety Inventory [STAIT-5]). In addition to assessing overall patient satisfaction, the level of patient satisfaction was stratified and compared according to levels of patient risk for preterm preeclampsia. RESULTS: Between June 2021 and December 2021, surveys were emailed to 765 participants. The response rate was 47.80% (358/765). Overall, 93% of participants reported high levels of satisfaction with preterm preeclampsia screening (70%–100%), and 98% stated that they would recommend the screening to all pregnant patients. With respect to levels of satisfaction with the program's support in reducing feelings of worry and anxiety, 87.9% of the total sample reported high satisfaction (70%–100%). The level of clinically significant symptoms of anxiety did not differ significantly between low- and high-risk groups (8% vs 10.8%, respectively). CONCLUSION: Overall, first-trimester preeclampsia screening was associated with high patient satisfaction and did not lead to differences in patient anxiety between those with high- and low-risk screen results.

A 68-year-old man presented for evaluation of a 5.0-cm asymptomatic ascending aortic aneurysm. He was managed medically until a family member was also diagnosed with a thoracic aortic aneurysm. His aneurysm was, therefore, likely to be genetically predisposed, and he underwent early prophylactic ascending aorta replacement. (Level of Difficulty: Beginner.)

Objective: In the present report, we have described the technical and clinical outcomes of percutaneous thrombectomy in the deep veins of the upper extremity and thorax using the ClotTriever system (Inari Medical, Irvine, CA). Methods: Fourteen patients with symptomatic deep venous occlusive disease in the upper extremity deep veins and thoracic central veins who had undergone thrombectomy using the ClotTriever system between October 2020 and January 2022 were reviewed. The technical results, adverse events, imaging follow-up data, and clinical outcomes were recorded. Results: Fourteen patients (seven men and seven women; mean age, 53.6 ± 13.3 years) constituted the study cohort. Of the 14 patients, 9 (64.3%) had had DVT due to intravascular invasion or external compression from known malignancy, 2 (14.3%) had had infected thrombi and/or vegetation due to Staphylococcus aureus refractory to intravenous antibiotic therapy, and 3 (21.4%) had had a benign etiology for thrombus formation. The presenting symptoms included upper extremity and/or facial swelling (n = 14), upper extremity pain (n = 6), fever (n = 2), and dyspnea (n = 1). Thrombectomy with the ClotTriever system was successfully completed in all 14 patients. Seven patients (50.0%) had required additional venous stent reconstruction after thrombectomy to address the underlying stenosis. No major adverse events were noted. All the patients had experienced resolution of the presenting symptoms. Conclusions: For the management of symptomatic deep venous occlusive disease of the upper extremity deep veins and thoracic central veins, thrombectomy using the ClotTriever system was feasible with excellent technical and clinical success.

Cardiac tamponade is a medical emergency requiring prompt recognition and intervention to avoid potentially fatal consequences. We present a case series of ventricular dysfunction and cardiogenic shock following pericardiocentesis in 3 patients with pericardial effusions at The Ottawa Hospital between 2014 and 2020. This report highlights the need for monitoring post-pericardiocentesis and raises awareness of this phenomenon, particularly in patients with malignancy. We propose a novel pressure-monitoring protocol to guide drainage and prevent development of pericardial decompression syndrome. The novel teaching points include limiting drainage to prevent development of pericardial decompression syndrome and a protocol for intra-pericardial pressure monitoring. RÉsumÉ: La tamponnade cardiaque est une urgence médicale qui, à défaut d’une reconnaissance et d’une intervention rapides, peut avoir des conséquences potentiellement fatales. Nous présentons une série de cas sur des dysfonctions ventriculaires et des chocs cardiogéniques survenus après une péricardiocentèse chez trois patients présentant des épanchements péricardiques traités à l’Hôpital d’Ottawa entre 2014 et 2020. Notre article souligne la nécessité de surveiller les patients au cours de la période suivant la péricardiocentèse et met en lumière le phénomène de la tamponnade cardiaque, en particulier chez les patients atteints de cancer. Nous proposons un nouveau protocole de surveillance des pressions conçu pour guider le drainage et prévenir le syndrome de décompression péricardique. Les nouveautés à enseigner comprennent la limitation du drainage afin de prévenir le syndrome de décompression péricardique et un protocole de surveillance des pressions intrapéricardiques.

Purpose: The clinical management of brain metastases after stereotactic radiosurgery (SRS) is difficult, because a physician must review follow-up magnetic resonance imaging (MRI) scans to determine treatment outcome, which is often labor intensive. The purpose of this study was to develop an automated framework to contour brain metastases in MRI to help treatment planning for SRS and understand its limitations. Methods and Materials: Two self-adaptive nnU-Net models trained on postcontrast 3-dimensional T1-weighted MRI scans from patients who underwent SRS were analyzed. Performance was evaluated by computing positive predictive value (PPV), sensitivity, and Dice similarity coefficient (DSC). The training and testing sets included 3482 metastases on 845 patient MRI scans and 930 metastases on 206 patient MRI scans, respectively. Results: In the per-patient analysis, PPV was 90.1% ± 17.7%, sensitivity 88.4% ± 18.0%, DSC 82.2% ± 9.5%, and false positive (FP) 0.4 ± 1.0. For large metastases (≥6 mm), the per-patient PPV was 95.6% ± 17.5%, sensitivity 94.5% ± 18.1%, DSC 86.8% ± 7.5%, and FP 0.1 ± 0.4. The quality of autosegmented true-positive (TP) contours was also assessed by 2 physicians using a 5-point scale for clinical acceptability. Seventy-five percent of contours were assigned scores of 4 or 5, which shows that contours could be used as-is in clinical application, and the remaining 25% were assigned a score of 3, which means they needed minor editing only. Notably, a deep dive into FPs indicated that 9% were TP metastases not identified on the original radiology review, but identified on subsequent follow-up imaging (early detection). Fifty-four percent were real metastases (TP) that were identified but purposefully not contoured for target treatment, mainly because the patient underwent whole-brain radiation therapy before/after SRS treatment. Conclusions: These findings show that our tool can help radiologists and radiation oncologists detect and contour tumors from MRI, make precise decisions about suspicious lesions, and potentially find lesions at early stages.

Background: Heart failure (HF) is a frequent cause of hospitalization and death in patients with atrial fibrillation (AF). Identifying AF patients at risk of HF hospitalization could help select individuals for intensive follow-up and treatment. Methods: We pooled data from 3 randomized trials (ACTIVE-A, RE-LY, AVERROES) of AF patients, for derivation and internal validation of a risk score for first HF hospitalization. Secondary endpoints were cardiovascular death and a composite of HF hospitalizations and cardiovascular death. Results: In 23,503 patients, the mean age was 71.3 years, and 62% were male. Over a mean follow-up of 2.0 years, 875 patients (3.7%) experienced their first HF hospitalization, and 1037 patients (4.4%) died from cardiovascular causes. Incidence rates per 100 patient-years were 1.85 for HF hospitalizations, 2.15 for cardiovascular death, and 3.71 for the composite. Independent predictors for HF hospitalizations included the following: increased age, weight, heart rate and serum creatinine level, lower height and systolic blood pressure, diabetes, vascular disease, valvular disease, heart rhythm, left ventricular hypertrophy, and intraventricular conduction delay. The C-statistic (95% confidence intervals by bootstrap simulations) was 0.717 (0.705-0.732). At 2 years of follow-up, the incidence rate of the primary outcome increased across risk-score quintiles: 0.49, 0.87, 1.29, 2.44, and 4.51 per 100 patient-years, respectively. Patients in the highest quintile had an absolute risk of 6.8% for the primary endpoint at 2 years. Conclusions: In a large AF population, new-onset HF was common. A combination of characteristics can identify high-risk patients for whom strategies to prevent HF should be considered. Résumé: Introduction: L’insuffisance cardiaque (IC) est une cause fréquente d’hospitalisation et de décès chez les patients atteints de fibrillation auriculaire (FA). Le repérage des patients atteints de FA exposés au risque d’hospitalisation liée à l’IC pourrait faciliter la sélection des individus pour un suivi et un traitement intensifs. Méthodes: Nous avons regroupé les données de trois essais contrôlés (ACTIVE-A, RE-LY, AVERROES) de patients atteints de FA pour obtenir la dérivation et la validation interne d’un score de risque lors de la première hospitalisation liée à l’IC. Les critères secondaires étaient les décès dus aux maladies cardiovasculaires et le critère composite d’hospitalisations liées à l’IC et de décès dus aux maladies cardiovasculaires. Résultats: L’âge moyen des 23 503 patients, dont 62 % étaient des hommes, était de 71,3 ans. Durant un suivi moyen de 2,0 ans, 875 patients (3,7 %) ont subi leur première hospitalisation liée à l’IC, et 1 037 patients (4,4 %) sont morts de maladies cardiovasculaires. Les taux d’incidence par 100 patients-années étaient de 1,85 pour les hospitalisations liées à l’IC, de 2,15 pour les décès dus aux maladies cardiovasculaires et de 3,71 pour le critère composite. Les prédicteurs indépendants des hospitalisations liées à l’IC étaient les suivants : l’âge avancé, le poids, la fréquence cardiaque et la concentration sérique de la créatinine, la taille inférieure et la pression artérielle systolique, le diabète, les maladies vasculaires, la valvulopathie, le rythme cardiaque, l’hypertrophie ventriculaire gauche et le retard de conduction intraventriculaire. La statistique C (intervalles de confiance à 95 % obtenus par simulations d’auto-amorçage) était de 0,717 (0,705-0,732). Après deux ans de suivi, le taux d’incidence du critère d’évaluation principal augmentait de façon respective dans tous les quintiles de scores de risque : 0,49, 0,87, 1,29, 2,44 et 4,51 par 100 patients-années. Les patients dans le quintile supérieur avaient un risque absolu du critère d’évaluation principal de 6,8 % après deux ans. Conclusions: Dans une vaste population atteinte de FA, l’IC d’apparition récente était fréquente. La combinaison des caractéristiques peut permettre de déterminer les patients exposés à un risque élevé chez lesquels des stratégies de prévention de l’IC devraient être envisagées.

Purpose: We present the case of a 48-year-old patient with recurrent World Health Organization grade II meningioma in the left occipital region who underwent a subtotal resection, followed by postoperative proton therapy to residual disease and the resection cavity. Fourteen months after radiation treatment completion, surveillance imaging revealed numerous ring-enhancing infratentorial lesions, both within and outside of the high-dose field, of concern for viable tumor. We describe the use of advanced imaging and proton biologic effectiveness analyses to enable the diagnosis of radiation necrosis (RN) and ascertain intrinsic physical factors contributing to the development of RN in this patient. Methods and Materials: Multiparametric magnetic resonance imaging (MRI) and Monte Carlo predictions of linear energy transfer (LET) and variable relative biologic effectiveness dose were performed. Results: The dosimetric analysis revealed that of the 10 lesions, 9 were located outside of the clinical treatment volume and 6 received a dose of

Background: The COVID-19 pandemic led to cancelation of all elective surgeries for a time period in the vast majority of the United States. We compiled a questionnaire to determine the physical and mental toll of this delay on elective total joint arthroplasty patients. Methods: All patients whose primary or revision total hip or knee arthroplasty was canceled because of the COVID-19 pandemic at a large academic-private practice were identified. An 11-question survey was administered to these patients via email. All data were deidentified and stored in a REDCAP database. Results: Of 367 total patients identified, 113 responded to the survey. Seventy-seven percent of patients had their surgery postponed at least 5 weeks, and 20% were delayed longer than 12 weeks. Forty-one percent of patients reported an average visual analog scale pain score greater than 7.5. Forty percent of respondents experienced increased anxiety during the delay. Thirty-four percent of patients felt their surgery was not elective. Sixteen percent experienced a fall during the delay, and 1 patient sustained a hip fracture. Level of pain reported was significantly associated with negative emotions, negative effects of delay, and whether patients felt their surgery was indeed elective. Seventy-six percent reported trust in their surgeon’s judgment regarding appropriate timing of surgery. Communication was listed as the number one way in which patients felt their surgeon could have improved during this time. Conclusion: Surgical delay due to the COVID-19 pandemic resulted in increased pain and anxiety for many total joint arthroplasty patients. While most patients maintained trust in their surgeon during the delay, methods to improve communication may benefit the patient experience in future delays. Level of Evidence: Level II.

Background: There is mounting evidence that smoking, abnormal body mass index (BMI), uncontrolled diabetes, and poor nutritional status are associated with complications after total hip arthroplasty (THA). The goal of the present study was to evaluate the consequences of failure to medically optimize Medicare-eligible patients with respect to these key modifiable health targets by assessing complications in the early postoperative period after THA. Methods: The National Surgical Quality Improvement Program database was queried for all primary THAs performed in 2018. Data were collected on preoperative serum albumin, BMI, diabetes, and tobacco use as well as postoperative infections, readmissions, complications, and mortality. We identified 47,924 THA patients with a median BMI of 29 kg/m2 and age of 72 years, and 60% of whom were female. Results: We found that preoperative albumin

Mesothelioma in situ is a recently described precursor to invasive mesothelioma. Thus far, all cases in the literature have involved one pleural cavity or the peritoneal cavity. We describe a patient with biopsy-proven mesothelioma in situ involving both pleural cavities and the peritoneal cavity. Genetic analysis results revealed that the patient had a BAP1 germline mutation. This is the first report of mesothelioma in situ involving multiple body cavities and raises a question of whether such patients will all have BAP1 germline mutations.

“Brain-predicted age” quantifies apparent brain age compared to normative neuroimaging trajectories. Advanced brain-predicted age has been well established in symptomatic Alzheimer disease (AD), but is underexplored in preclinical AD. Prior brain-predicted age studies have typically used structural MRI, but resting-state functional connectivity (FC) remains underexplored. Our model predicted age from FC in 391 cognitively normal, amyloid-negative controls (ages 18–89). We applied the trained model to 145 amyloid-negative, 151 preclinical AD, and 156 symptomatic AD participants to test group differences. The model accurately predicted age in the training set. FC-predicted brain age gaps (FC-BAG) were significantly older in symptomatic AD and significantly younger in preclinical AD compared to controls. There was minimal correspondence between networks predictive of age and AD. Elevated FC-BAG may reflect network disruption during symptomatic AD. Reduced FC-BAG in preclinical AD was opposite to the expected direction, and may reflect a biphasic response to preclinical AD pathology or may be driven by inconsistency between age-related vs. AD-related networks. Overall, FC-predicted brain age may be a sensitive AD biomarker.

Revision total knee arthroplasty often necessitates removing well-fixed components. Tibial tray removal is challenging becaue of 1) physical barriers posed by the component pegs, keel, or stem in accessing the implant-bone interface circumferentially and 2) proximity of vulnerable structures including the patellar tendon, collateral ligaments, popliteal artery, and distal femur. In this report, we present a step-by-step technique for removal of a well-fixed tibial component using a single-sided reciprocating saw.

A 62-year-old man presented with a history of atypical meningioma (World Health Organization grade II) and recurrent as anaplastic meningioma (World Health Organization grade III). His previous treatments included multiple surgical resections, fractionated radiation therapy, stereotactic radiosurgery, everolimus/octreotide long-acting release, bevacizumab, and hydroxyurea. Magnetic resonance imaging revealed rapid volumetric progression over the prior 9 months, with a near tripling in size from 29.9 cm3 to 80.4 cm3. Indium In 111 octreotide scanning confirmed the presence of somatostatin receptors within the tumor. Lutetium Lu 177 dotatate was administered intravenously at a dose of 200 mCi per dose every 8 weeks for 4 cycles. Treatment was tolerated very well, with no notable adverse events. Tumor volume initially increased to 98.3 cm3 after cycle 1 of treatment and subsequently decreased to 91.2 cm3 after cycle 2. Eight months after treatment onset, the tumor volume remained stable (93.4 cm3).

Permanent junctional reciprocating tachycardia (PJRT) is a rare form of atrioventricular reentrant tachycardia that is commonly resistant to most antiarrhythmic medication therapy and over an extended duration can result in tachycardia-induced cardiomyopathy. The prenatal presentation of PJRT is typically similar to that of other types of fetal supraventricular tachycardia (SVT), making it difficult to distinguish from other forms of SVT in utero by fetal echocardiography. Surface electrocardiography after delivery is typically required to make a definitive diagnosis of PJRT. We report a case of fetal SVT at 19 weeks’ gestation refractory to maternal transplacental treatment with digoxin, amiodarone, flecainide, sotalol, metoprolol, intraumbilical amiodarone, and fetal intramuscular digoxin over the course of 12 weeks. Repeat cesarean delivery was performed at 30 2/7 weeks’ gestation for tachycardia-induced cardiomyopathy with hydrops fetalis. Postnatal electrocardiogram and continuous rhythm monitoring confirmed the diagnosis of PJRT. Combined neonatal treatment with amiodarone, digoxin, and propranolol was successful in reestablishment of sinus rhythm, with radiofrequency ablation planned if medical therapy eventually fails or once early childhood is reached. To our knowledge, this is the first described case of fetal PJRT refractory to multiple standard in utero antiarrhythmic modalities and highlights the importance of inclusion in the differential diagnosis.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare type of T-cell lymphoma that arises in the setting of textured breast implants. In this case report, a 69-year-old woman with a remote history of right-sided invasive lobular carcinoma status post right mastectomy and bilateral breast reconstruction presents with spontaneous right breast swelling and pain, suspicious for implant rupture. Diagnostic MRI revealed a peri-implant fluid collection in the right breast and focal nonmass enhancement in the left breast. The patient was ultimately diagnosed with right-sided BIA-ALCL and left-sided invasive lobular carcinoma. Although intravenous gadolinium contrast is not needed to assess implant integrity, it can be used to evaluate for malignancy when the patient is at an increased risk for developing breast cancer. In this case, the use of contrast revealed the rare instance of a synchronous contralateral invasive lobular carcinoma. Despite the rarity of BIA-ALCL with an estimated incidence of 1:30,000 in women with textured implants, it is essential that radiologists include this entity in the differential in the appropriate clinical setting as surgical resection is curative if performed before the disease has spread.

Introduction: BRAF mutations are rare in patients with NSCLC, and treatment options are limited. Dabrafenib plus trametinib (dab-tram) was approved for BRAFV600-mutated advanced NSCLC (aNSCLC), based on results from a phase 2 study (NCT01336634). This retrospective analysis compared the effectiveness of dab-tram, based on previously reported clinical trial data, versus real-world standard of care in patients with BRAF-mutated aNSCLC. Methods: Real-world cohorts were derived from a deidentified real-world database (2011–2020) and included patients with BRAF-mutated aNSCLC receiving first-line platinum-based chemotherapy (PBC), first-line immune checkpoint inhibitors (ICIs) plus PBC, or second-line ICIs. Weighting by odds was used to estimate the average treatment effect of the treated. Results: For first-line dab-tram versus PBC, the hazard ratio (HR; 95% confidence interval) for death in unweighted and weighted analyses was 0.65 (0.39–1.1) and 0.51 (0.29–0.92; p = 0.03), respectively; unweighted and weighted median overall survival was 17.3 (12.3–40.2) versus 14.5 (9.2–19.6) months and 17.3 (14.6-not reached) versus 9.7 (6.4–19.6) months, respectively. Hazard ratio of death in unweighted and weighted analyses was 0.56 (0.29–1.1) and 0.57 (0.28–1.17), respectively, with first-line dab-tram versus PBC plus ICI, and 0.65 (0.39–1.07) and not reported (Cox proportional-hazards assumption violated), respectively, with second-line dab-tram versus ICI. Conclusions: In this indirect comparison in patients with BRAF-mutated aNSCLC, the risk of death was lower and median overall survival was longer with first-line dab-tram versus PBC. In analyses of dab-tram versus first-line PBC plus ICI or second-line ICI, sample sizes were small and findings were inconclusive with overlapping confidence intervals. Despite some limitations, the study provides useful data for this rare patient population.

Purpose: To evaluate differences in the retinal microvasculature and structure and choroidal structure among men and women with Alzheimer’s disease (AD) compared with age-matched cognitively normal male and female controls. Design: Case-control study of participants ≥ 50 years of age. Participants: A total of 202 eyes of 139 subjects (101 cases and 101 controls). Methods: All participants and controls underwent OCT and OCT angiography (OCTA), and parameters of subjects with AD were compared with those of cognitively normal controls. Main Outcome Measures: The foveal avascular zone (FAZ) area, vessel density (VD), and perfusion density (PD) in the superficial capillary plexus within the 3- and 6-mm circle and ring using Early Treatment Diabetic Retinopathy Study (ETDRS) grid overlay on OCTA; central subfield thickness (CST), retinal nerve fiber layer (RNFL) thickness, ganglion cell-inner plexiform layer (GCIPL) thickness, and choroidal vascularity index (CVI) on OCT. Results: No significant sex differences in VD or PD were found in the AD or control cohorts; however, there were greater differences in VD and PD among AD female participants than AD male participants compared with their respective controls. The CST and FAZ area were not different between male and female AD participants. Among controls, men had a thicker CST (P < 0.001) and smaller FAZ area (P = 0.003) compared with women. The RNFL thickness, GCIPL thickness, and CVI were similar among male and female AD participants and controls. Conclusions: There may be a loss of the physiologic sex-related differences in retinal structure and microvasculature in those with AD compared with controls. Further studies are needed to elucidate the pathophysiological basis for these findings.

Hepatic artery aneurysms (HAA) are rare and may be seen in the setting of infection and vascular disease. Clinical presentation is variable but many are found incidentally during imaging studies. The association of HAA with focal nodular hyperplasia (FNH) is rarely reported in literature. We present the case of a 68-year-old woman found to have a hepatic artery aneurysm and hepatic mass, both within the same liver segment. FNH and hepatic adenomas share similar imaging features but have different treatments due to malignant potential of the latter, and biopsy should be performed when adenoma cannot be excluded. In this case biopsy of the mass revealed it to be FNH and the aneurysm was treated with embolization rather than surgery.