Search

Intraoperative neuromonitoring (IONM) has been used in neurosurgical procedures to assess patient safety and minimize risk of neurological deficit. However, its use in decompressive surgeries of Chiari malformation type I (CM-I) remains a topic of debate. Here we present the case of a 5-year-old girl who presented with acute right lower extremity monoplegia after accidental self-induced hyperflexion of the neck while playing. Imaging revealed 15 mm of tonsillar ectopia with cervical and upper thoracic spinal cord edema. She was taken to surgery for a suboccipital decompression with expansile duraplasty. IONM demonstrated improvement in motor evoked potentials during the decompression. Postoperatively, she had full recovery of strength and mobility. This is a case of acute weakness after mild trauma in the setting of previously asymptomatic CM-I that showed close correlation with IONM, clinical findings, and imaging. IONM during decompressive surgery for CM-I may be useful in patients who present acutely with cervical cord edema.

Objective: The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry.Methods: The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients’ data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5.Results: Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. ‘Severely frail’ patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21–35.44) for 30-day mortality, 3.02 (95% CI, 1.97–4.56) for major complications, and 2.94 (95% CI, 2.32–4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality.Conclusion: Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.

Background Pulmonary arteriovenous malformations (PAVM) are pathological connections between arterial and venous circulations in the lung. The anomalous channel provides a conduit for emboli of venous origin to migrate paradoxically. With access to systemic circulation, thromboembolic processes such as deep vein thrombosis may increase the risk of cerebrovascular accidents such as acute ischemic strokes (AIS). This retrospective cross‐sectional study aims to characterize the contribution of PAVMs to the development of AIS in the setting of thromboembolic processes. Methods The 2010 to 2019 National Inpatient Sample was queried for patients with PAVM and AIS using International Classification of Diseases, Ninth/Tenth Revision ( ICD‐9 ; ICD‐10 ) codes. Baseline demographics and outcomes of interest, including complications and hospitalization metrics, were retrospectively analyzed. Results Of 7 465 187 patients treated for an AIS, 1 864 (0.02%) were found to have a concomitant PAVM. Multivariate regression found patients with AIS‐PAVM were more likely to be aged Conclusion Given the relative rarity of PAVMs, a high index of suspicion, especially in the setting of deep vein thrombosis, is necessary to identify this condition in a timely manner when evaluating cryptogenic AIS. Abnormal right‐to‐left shunting through pulmonary vasculature may serve as a conduit for the translation of a deep vein thrombosis paradoxically into a distal occlusion of cerebral arteries. Our findings substantiate that AIS may follow a vastly different disease process in patients with PAVM.

Objective A new automated and adjustable blood pressure (BP) system has been developed to improve the accuracy of BP measurements on public-use health stations. This self-fitting BP system includes a mechanical cuff that wraps down to the user's arm prior to bladder inflation. The purpose of this study was to validate the adaptable BP system (ABPS) using the current standards from the Association for the Advancement of Medical Instrumentation (AAMI). Methods The AAMI/ISO 81060:2013 standards for clinical validation of non-invasive automated arterial BP measurement devices were followed precisely using the same arm sequential method. For each participant, BP was measured over multiple trials by trained observers alternating a reference sphygmomanometer with the ABPS. All study requirements were met with 85 qualifying participants, each with 3 valid paired determinations. Results The mean difference between ABPS BP and reference BP using all 255 paired determinations was -2.4 ± 7.7 mmHg for systolic and 1.7 ± 5.7 mmHg for diastolic. The standard deviation of the averaged paired determinations per participant was 6.3 mmHg for systolic and 5.2 mmHg for diastolic. Arm circumference measurements had a mean error of -2.1 ± 2.4 cm (R2 = 0.87). A new prediction model for arm circumference was validated using a holdout dataset (R2 = 0.94). Conclusion The results of the study confirm that the ABPS met all benchmarks established by the AAMI. The device accurately measures BP across a wide range of arm circumferences (24-44 cm) and is suitable for use by individuals to self-monitor BP.

Approximately 65% of moderate-to-severe traumatic brain injury (m-sTBI) patients present with poor long-term behavioural outcomes, which can significantly impair activities of daily living. Numerous diffusion-weighted MRI studies have linked these poor outcomes to decreased white matter integrity of several commissural tracts, association fibres and projection fibres in the brain. However, these studies focused on group-based analyses, which are unable to deal with the substantial between-patient heterogeneity in m-sTBI. As a result, there is increasing interest in conducting individualised neuroimaging analyses. Here, we generated a detailed subject-specific characterisation of microstructural organisation of white matter tracts in 5 chronic patients with m-sTBI (29 – 49y, 2 females). We developed an imaging analysis framework using fixel-based analysis and TractLearn to determine whether the values of fibre density of white matter tracts at the individual patient level deviate from the healthy control group (n = 12, 8F, Mage=35.7y, age range 25 – 64y). Our individualised analysis confirmed unique white matter profiles, and the heterogeneous nature of m-sTBI to properly characterise the extent of brain abnormality. Future studies incorporating clinical data, as well as utilising larger reference samples and examining the test-retest reliability of the fixel-wise metrics are warranted. This proof-of-concept study suggests that these resulting individual profiles may assist clinicians in planning personalised training programs for chronic m-sTBI patients, which is necessary to achieve optimal behavioural outcomes and improved quality of life.

Introduction Acute kidney injury (AKI) is associated with poor outcome in aneurysmal subarachnoid hemorrhage patients (aSAH). Frailty has recently been demonstrated to correlate with elevated mortality and morbidity; its impact on predicting AKI and mortality in aSAH patients has not been investigated. Objective Evaluating risk factors and predictors for AKI in aSAH patients. Methods aSAH patients from a single-center's prospectively maintained database were retrospectively evaluated for development of AKI within 14 days of admission. Baseline demographic and clinical characteristics were collected. The effect of frailty and other risk factors were evaluated. Results Of 213 aSAH patients, 53 (33.1%) were frail and 12 (5.6%) developed AKI. Admission serum creatinine (sCr) and peak sCr within 48 h were higher in frail patients. AKI patients showed a trend towards higher frailty. Mortality was significantly higher in AKI than non-AKI aSAH patients. Frailty was a poor predictor of AKI when controlling for Hunt and Hess (HH) grade or age. HH grade ≥ 4 strongly predicted AKI when controlling for frailty. Conclusion AKI in aSAH patients carries a poor prognosis. The HH grade appears to have superior utility as a predictor of AKI in aSAH patients than mFI.

Background After MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) demonstrated that endovascular therapy improved outcomes in patients with stroke, the number of endovascular procedures has risen sharply. We describe acute transient contrast‐induced neurological deficit (ATCIND), a group of neurological syndromes associated with arterial contrast administration during angiography. Our goal is to elucidate the incidence, risk factors, outcomes, pathogenesis, and diagnostic characteristics of ATCIND. Our primary objective is to elucidate the incidence of ATCIND in the setting of coronary or cerebral angiography. Secondary outcomes include potential risk factors, demographics, treatment modalities, and patient recovery. Methods The data that support the findings of this study are available from the corresponding author on reasonable request. The databases of the Cochrane Library, MEDLINE, Web of Science, and Embase were queried, yielding studies from 1974 to 2021. Inclusion criteria for articles were the following: (1) contrast‐induced encephalopathy, contrast‐induced neurotoxicity, or cortical blindness after contrast administration during angiography were the focus of the article; (2) incidence was reported; (3) studies included ≥3 cases; and (4) follow‐up tests were described to rule out other causes. Exclusion criteria included the following: (1) incidence was not reported; (2) unavailable in the English language; (3) abstracts and unpublished studies; and (4) did not exclude other possible causes, or findings suggested other possible causes, such as worsening ischemic injury. Of 627 articles, 7 were retained. This systematic review with meta‐analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) and the Meta‐Analysis of Observational Studies in Epidemiology (MOOSE) checklists. Independent extraction by multiple reviewers was performed. Data were pooled using a random‐effects model. Results The primary study outcome was incidence of ATCIND, which was formulated before data collection began. We hypothesized that the pooled incidence of ATCIND would be similar to that of individual studies. A total of 70 of 21007 patients had the diagnosis of contrast‐induced encephalopathy, contrast‐induced neurotoxicity or angiography‐associated cortical blindness, and ATCIND. The incidence rate of ATCIND is estimated to be 0.51% (CI, 0.3%–1.0%; P I 2 =29.3]), or 51 per 10 000 patients. Pooled data for risk factors for contrast‐induced encephalopathy were higher contrast dose (odds ratio [OR], 1.072; 95% CI, 0.952–1.192 [ P I 2 =0), and prior stroke (OR, 5.153; CI 1.726–8.581 [ P =0.003]; I 2 =0). Contrast dose >150 mL was a positive, significant predictor of visual disturbance (OR, 7.083; CI, 1.1742–42.793 [ P =0.033]). Full recovery is estimated at 89.5% (95% CI, 76.9%–95.6%; P I 2 =0]). Conclusions This study confirms the rare incidence of ATCIND, although it shows moderate heterogeneity, likely reflecting the type of angiography performed. Risk factors include larger contrast dose and prior stroke. Full recovery occurs in the majority of patients. It should remain in the differential diagnosis in patients with certain risk factors for blood–brain barrier compromise.

The scientific interest in two-dimensional topological insulators (2D TIs) is currently shifting from a more fundamental perspective to the exploration and design of novel functionalities. Key concepts for the use of 2D TIs in spintronics are based on the topological protection and spin-momentum locking of their helical edge states. In this study we present experimental evidence that topological protection can be (partially) lifted by pairwise coupling of 2D TI edges in close proximity. Using direct wave function mapping via scanning tunneling microscopy/spectroscopy (STM/STS) we compare isolated and coupled topological edges in the 2D TI bismuthene. The latter situation is realized by natural lattice line defects and reveals distinct quasi-particle interference (QPI) patterns, identified as electronic Fabry-Pérot resonator modes. In contrast, free edges show no sign of any single-particle backscattering. These results pave the way for novel device concepts based on active control of topological protection through inter-edge hybridization for, e.g., electronic Fabry-Pérot interferometry.

Introduction Between the indications for endomyocardial biopsy (EMB) is the study of patients with heart failure associated with restrictive or infiltrative cardiomyopathy, such as cardiac amyloidosis if another workup is inconclusive. Although a risk-procedure, EMB is recommended in clinical scenarios in which the unique prognostic and diagnostic value of the information gained is felt to outweigh the procedural risks. Purpose We want to know the diagnostic value of EMB in the scenario of suspected cardiac amyloidosis and the role of the place of EMB for diagnosis. Methods We prospectively collected patients from our center with infiltrative cardiomyopathy and suspected cardiac amyloidosis who were referred to perform EMB. We gathered data on diagnostic profitability considering two different groups: those with samples from the right ventricle (group 1) and those with samples from the left ventricle (group 2; 90.8% with transradial approach). We consider major complications myocardial perforation, pericardial tamponade, arrhythmias, or bleeding with hemodynamic instability and death. Results We collected data from 111 patients referred for EMB for infiltrative cardiomyopathy suspicion. We present the results in table 1. The most common diagnosis was cardiac amyloidosis for wild-type transthyretin (43.48% in group 1 and 58.46% in group 2). There were no complications in the patients with confirmed cardiac amyloidosis in group 2. Conclusions In our EMBs for infiltrative cardiomyopathy suspicion we found that patients undergoing left-sided EMB had a shorter time of X-ray exposure and less time of admission without any other risk associated. So, we conclude that EMBs performed in the left heart are secure and comfortable for patients and physicians. Funding Acknowledgement Type of funding sources: None.

This study aimed to compare operative time, blood loss, and transfusion requirement in patients receiving a high tranexamic acid (TXA) dose of greater than 10 mg/kg versus those receiving a low dose of 10 mg/kg or less.PubMed, Cochrane Central, and Embase were queried to perform a systematic review with meta-analysis. Studies reporting outcomes of TXA use in craniosynostosis surgery were included. TXA dosing, operative time, blood loss, and transfusion requirement were the primary outcomes studied. Other variables studied included age and types of craniosynostosis.In total, 398 individuals in the included articles received TXA for craniosynostosis surgery. TXA loading doses ranged from 10 mg/kg to 50 mg/kg. Overall, administration of TXA was not associated with changes in operative time, but was associated with decreased blood loss and transfusion requirement on meta-analysis. Comparison of high dose TXA (10 mg/kg) versus low dose (10 mg/kg or less) showed no statistical differences in changes in operative time, blood loss, or transfusion requirement.Overall, TXA reduced blood loss and transfusion requirement in patients undergoing surgery for craniosynostosis. There was no difference in outcomes between high dose and low dose regimens amongst those receiving TXA. Low dose TXA appears adequate to achieve clinical efficacy with a low adverse event rate.

INTRODUCTION: The alar ligament is an important structure in restraining the rotational movement at the atlantoaxial joint. While bony fractures generally heal, rupture of ligaments may heal poorly in adults and often requires surgical stabilization. Atlantoaxial rotatory subluxation (AARS) is a rare injury in adults, and the prognostic importance of the presence of alar ligament injury with regard to the success of nonoperative management is unknown. CASE PRESENTATION: A 28-year-old woman presented after a traumatic Type I AARS without evidence of osseous injury, but MRI demonstrated evidence of unilateral alar ligament disruption. Initial conservative management with closed reduction and maintenance in a rigid cervical collar proved unsuccessful, with worsening pain and failure to maintain reduction. She subsequently underwent open reduction and surgical fixation of C1-C2, resulting in resolution of her pain and maintenance of alignment. DISCUSSION: Alar ligament rupture may be a negative prognostic indicator in the success of nonoperative management of type I atlantoaxial rotatory subluxation. Additional study is warranted to better assess whether the status of the alar ligament should be considered an important factor in the management algorithm of type I AARS.

Introduction: Subarachnoid hemorrhage (SAH) can be a devastating neurologic condition that leads to cardiac arrest (CA), and ultimately poor clinical outcomes. Existing literature on this subject reveal a dismal prognosis when analyzing relatively small sample sizes. We aimed to further elucidate the incidence, mortality rates, and outcomes of CA patients with SAH using large-scale population data. Methods: A retrospective cohort study was conducted using the National Inpatient Sample (NIS) database. Patients included in the study met criteria using International Classification of Diseases (ICD) codes 9th and 10th edition of: non-traumatic SAH, CA cause unspecified, and CA due to other underlying conditions between 2008 and 2014. For all regression analyses, a p-value of Results: We identified 170,869 patients hospitalized for non-traumatic SAH. Within these, there was a 3.17% incidence of CA. The mortality rate in CA with SAH was 82% (vs non-CA 18.4%, p< 0.001). Of the survivors of CA with SAH, 15.7% were discharged to special facilities and services (vs non-CA 37.6%, p Conclusion: The study confirms the poor prognosis of patients with CA and SAH using large-scale population data. Patients that underwent aneurysm treatment show lower association with CA. Findings presented here provide useful data for clinical decision making and guiding goals of care discussion with family members. Further studies may identify interventions and protocols for treatment of these severely ill patients.

The Mechanistic Target of Rapamycin (mTOR), which functions in two distinct multiprotein complexes, mTORC1 and mTORC2, is a downstream signaling kinase in the PI3K/AKT pathway. mTOR is often deregulated in glioblastoma (GB), the most aggressive primary brain tumor in adults, due to the frequent loss of the tumor suppressor, PTEN. mTORC1 and mTORC2 control cell growth, proliferation, migration, survival, and stem cell regulation in response to nutrients and growth factors. Nutrient-sensitive mTORC1 regulates protein synthesis through the downstream substrate, 4EBP1 (also called EIF4EBP1), p70S6K1, and p70S6K2. On the other hand, growth factor-sensitive mTORC2 is associated with Rapamycin-insensitivity. The presence of stem cells within the tumor mass and the surrounding areas precludes the possibility of the elimination of GB. Furthermore, the substrate of activated AKT, the proline-rich AKT substrate of 40 kDa (PRAS40), is a surrogate marker of activated AKT in response to mTOR inhibition therapy in GB patients that regulates mTORC1. The aim of this study is to evaluate the efficacy of first (Rapamycin (RAPA)), second (Torin1, Torin2, and XL388), and third (Rapalink-1) mTOR inhibitors to suppress cell growth, dissemination, overcome drug resistance of GB cells, and alter self-renewal properties of GB stem cells. Results demonstrated: a significant number of tumors showed an increased expression of pAKTSer473 and pmTORSer2448, suggesting an overactivation of the mTOR pathway; co-expression of mTOR and stem cell marker, nestin, was evident in GB tumors, implying its role in stem cell regulation; Torin2, but not Torin1 or XL388, suppressed mTORC1 activity completely as shown by the reduced expression of its pS6KSer235/236 in a dose-dependent manner; Torin1, Torin2, and XL388 inhibited the phosphorylation of 4E-BP1 and PRAS40; Torin1, Torin2, and XL388 suppressed dephosphorylation of pAKTSer473; functional analysis revealed that RAPA, Torin1, Torin2, XL388, and Rapalink-1 effectively suppressed proliferation and S-phase entry; RAPA, Torin1, Torin2 and Rapalink-1 inhibited GB cell migration, while XL388 was ineffective; RAPA, Torin1, Torin2, and Rapalink-1 suppressed the self-renewal of GB stem cells and inhibited their proliferation, XL388 remained ineffective; drug resistance analysis revealed that Torin2 was most effective in eradicating GB tumor cells. These results suggested that RAPA, Torin1, Torin2, and Rapalink-1, but not XL388, are useful in suppressing the mTORC1 and mTORC2 activities, thereby inhibiting GB cell proliferation, dissemination, and inhibiting stem cell self-renewal. Therefore, the use of these mTOR inhibitors presents a promising treatment strategy for Glioblastoma. Citation Format: Jose F. Dominguez, Haylen Rosberger, Paul Garell, Chirag D. Gandhi, Meena Jhanwar-Uniyal. First, second, and third generation mTOR pathways inhibitors for treatment of glioblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5410.

There are known classifications that describe thoracolumbar (TL) burst type injury but it is unclear which have the most influence on management. Our objective is to investigate the association of classification publications with the quantity and type of the most influential articles on TL burst fractures.Web of Science was searched, and exclusion and inclusion criteria were used to extract the top 100 cited articles on TL burst fractures. The effects on type, number, and other variables were separated into four eras as defined by four major classification publications.30 out of the top 100 articles represent level 1 or 2 evidence. The most influential journal wasIn 1994, two articles marked the beginning of an era of highly influential TL burst fracture literature. The 2005 TLICS score was associated with a preceding increase in LOE and productivity. Following 2005, the literature saw a decrease in productivity and an increase in systematic review/meta-analysis (SR-MAs). These trends represent an increase in scholarly discussion that led to a systematic synthesis of the existing literature after publication of the 2005 TLICS article.

Epilepsy is a chronic seizure disorder that affects about 1% of the global population.1 When seizure freedom cannot be obtained solely through antiseizure medicines (ASMs), the condition is termed medically refractory epilepsy (MRE).2,3 Though posterior quadrant disconnection (PQD) is underutilized in our experience, it is a highly effective surgical procedure for MRE restricted to the temporal, parietal, and/or occipital lobes.4-12 In this operative video, we demonstrate a right-sided completion PQD following failed temporal lobectomy in an 8-yr-old female with focal MRE. We review technical nuances, including (1) extension/revision of prior scalp incision, (2) placement of subdural strip for the identification of phase reversal and central sulcus, (3) disconnection of parietal and occipital lobes, (4) extension of the corticectomy to the pia overlying the falcotentorial junction and into the prior temporal lobectomy defect, and (5) posterior disconnection of the corpus callosum. Postoperatively, the patient experienced subtle left-arm weakness and central fever, both of which resolved. An external ventricular drain (EVD) was placed in the ventricle/operative cavity and left for 3 to 4 d until the draining cerebrospinal fluid (CSF) cleared. As of 3-mo follow-up, she has been seizure-free without complications. In summary, PQD is a safe and effective treatment option for MRE that can be utilized not only as an initial operation but also after failed surgery. Appropriate patient consent was obtained to perform this procedure and present this clinical case and surgical video for academic purposes. Image at 4:00 licensed under CC BY-2.5, 2006, modified from http://upload.wikimedia.org/wikipedia/commons/7/70/Lateral_head_skull.jpg (flipped and rotated). Image at 4:42, Public Domain: Gray H. Anatomy of the Human Body. 1918. Bartleby.com, https://commons.wikimedia.org/wiki/File:Lobes_of_the_brain_NL.svg; flipped, modified. Image at 6:42, Public Domain: House EL, Pansky B. A Functional Approach to Neuroanatomy. 1960. McGraw-Hill Book Company; https://upload.wikimedia.wikipedia.commons/5/52/Lawrence_1960_2.3.png; modified.

OBJECTIVE Primary spinal meningiomas represent a rare indolent neoplasm usually situated in the intradural-extramedullary compartment. They have a predilection for afflicting the thoracic spine and most frequently present with sensory and/or motor symptoms. Resection is the first-line treatment for symptomatic tumors, whereas other clinical factors will determine the need for adjuvant therapy. In this study, the authors aimed to elucidate clinical presentation, functional outcomes, and long-term outcomes in this population in order to better equip clinicians with the tools to counsel their patients. METHODS This is a retrospective analysis of patients treated at the authors’ institution between 1998 and 2018. All patients with thoracic meningiomas who underwent resection and completed at least one follow-up appointment were included. Multiple preoperative clinical variables, hospitalization details, and long-term outcomes were collected for the cohort. RESULTS Forty-six patients who underwent resection for thoracic meningiomas were included. The average age of the cohort was 59 years, and the median follow-up was 53 months. Persistent sensory and motor symptoms were present in 29 patients (63%). Fifteen lesions were ventrally positioned. There were 43 WHO grade I tumors, 2 WHO grade II tumors, and 1 WHO grade III tumor; the grade III tumor was the only case of recurrence. The median length of hospitalization was 4 days. Seventeen patients (37%) were discharged to rehabilitation facilities. Thirty patients (65.2%) experienced resolution or improvement of symptoms, and there were no deaths within 30 days of surgery. Only 1 patient developed painful kyphosis and was managed medically. Ventral tumor position, new postoperative deficits, and length of stay did not correlate with disposition to a facility. Age, ventral position, blood loss, and increasing WHO grade did not correlate with length of stay. CONCLUSIONS Outcomes are overall favorable for patients who undergo resection of thoracic meningiomas. Symptomatic patients often experience improvement, and patients generally do not require significant future operations. Tumors located ventrally, while anatomically challenging, do not necessarily herald a significantly worse prognosis or limit the extent of resection.

BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection is associated with hypercoagulability. We sought to evaluate the demographic and clinical characteristics of cerebral venous thrombosis among patients hospitalized for coronavirus disease 2019 (COVID-19) at 6 tertiary care centers in the New York City metropolitan area. MATERIALS AND METHODS: We conducted a retrospective multicenter cohort study of 13,500 consecutive patients with COVID-19 who were hospitalized between March 1 and May 30, 2020. RESULTS: Of 13,500 patients with COVID-19, twelve had imaging-proved cerebral venous thrombosis with an incidence of 8.8 per 10,000 during 3 months, which is considerably higher than the reported incidence of cerebral venous thrombosis in the general population of 5 per million annually. There was a male preponderance (8 men, 4 women) and an average age of 49 years (95% CI, 36–62 years; range, 17–95 years). Only 1 patient (8%) had a history of thromboembolic disease. Neurologic symptoms secondary to cerebral venous thrombosis occurred within 24 hours of the onset of the respiratory and constitutional symptoms in 58% of cases, and 75% had venous infarction, hemorrhage, or both on brain imaging. Management consisted of anticoagulation, endovascular thrombectomy, and surgical hematoma evacuation. The mortality rate was 25%. CONCLUSIONS: Early evidence suggests a higher-than-expected frequency of cerebral venous thrombosis among patients hospitalized for COVID-19. Cerebral venous thrombosis should be included in the differential diagnosis of neurologic syndromes associated with SARS-CoV-2 infection.

The human brain is a dynamic network comprised of elements which are structurally connected and functionally interactive. A tight structure-function relationship is vital for this system to produce seamless cognition and behaviour. Brain injuries due to either neurological disease or single-event injuries alter the dynamics of normal structure-function interaction, resulting in poor neurobehavioural outcomes for patients. This scoping review is a synthesis of recent progress in understanding how brain injuries alter the structure-function relationship. We identified 16 studies that investigated the structure-function relationship in brain-injured cohorts, using fMRI and either T1-weighted or diffusion-weighted MRI to calculate, respectively, grey matter density or structural connectivity. Overall, a reduced structure-function relationship was found in brain-injured patients relative to healthy controls. This weakened relationship coincided with impaired cognition. Structural and functional MRI information should also be reconciled into suitable graph theoretical frameworks such as the multilayer network approach

Introduction The standard modifiable cardiovascular risk factors (SMuRFs), like diabetes mellitus, hyperlipidemia,hypertension and smoking, are central elements of the well-established European Society of Cardiology SCORE calculator. However, acute coronary syndromes (ACS) in SMuRF-less individuals are not uncommon. Purpose Our study aimed to describe the population with and without SMuRFs attended for an ACS and study prognostic factors associated with mortality. Methods We identified 1347 ACS patients without prior history of cardiovascular disease (ACS, cerebrovascular or peripheral artery disease)attended in our university hospital between 2009 and 2012 and examined the proportion of SMuRF-less patients as well as outcomes.The primary outcome was 5-year all-cause death. Results Overall, the median age was 63 years, 73.4% were male and 52 patients (7%)had no SMuRFs. The most common SMuRF was hypertension (60%), followed by smoking (47%), dyslipidemia (48%) and diabetes mellitus (27%). In patients with and without SMuRFs there were no differences in the proportion of females (27% vs 28%), age (63.7 years [IQR 54–75] vs 62 years [IQR 53–71]), renal failure (4.7% vs 0%, p=0.159), prior heart failure (1.6% vs 1.9%, p=0.590) and pulmonary obstructive disease (11.3% vs 9.6%, p=0.707). SMuRF-less patients had substantially less angina in the previously month (1.9% vs 19.1%, p Conclusion The absence of SMuRFs was not an independent predictor of mortality. Our study highlights the importance of the often-overlooked subgroup of ACS patients with atherosclerosis not predicted by SMuRFs. Funding Acknowledgement Type of funding source: None

For companies operating within the garment manufacturing industry, having frequent downtimes in their production flows is an extremely common issue. In this context, a balanced production line is required to prevent high waiting times due to limited productive capacity. A well-balanced assembly line allows products to be produced in an optimum time while using less resources, such as machines, materials, or labour, since the right number of products is produced with the exact amount of resources, thus generating savings in production costs. This paper seeks to foster optimum resource allocation through the line balancing tool. Finally, to define a work methodology, best practices were selected, and a procedures manual was developed focusing on Standardization. Both tools were implemented after implementing changes to the company culture by means of the Employee Empowerment tool. As a result of this implementation, workers acquired greater accountability and control over the resources, methods, and equipment of their work areas. After the proposed improvements had been deployed, the company reported an increase of over 20% in production line quality, performance, and efficiency.

Several factors compel graphic design companies to improve efficiency and competitiveness in their production lines. However, these companies are not prepared to take on this challenge, as they report delays in 20% of their deliveries, caused by high setup times, low machine availability, and poor work scheduling. In this context, this study proposes a new production management model fed by the interaction of lean manufacturing tools and the Johnson scheduling method. This model has been validated by direct application at the SISSA. The results obtained were the reduction of the setup time to 15 minutes, increased machine availability up to 24%, and an efficient scheduling of its tasks. All of these reduced the percentage of delivery delays from 20% to 6%.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. In recent years, homegrown SMEs have had low production levels when compared with Chinese garment imports, losing their competitive advantage in the domestic market. SMEs represent 96% of garment companies in Peru and have a positive impact on the creation of jobs. The search for a technique to improve SME output was conducted in various studies; however, the efforts did not bear fruit over time. Thus, this article seeks to improve the low production efficiency in textile and clothing SMEs. Therefore, we proposed a model and validated it in the production area of a denim clothing manufacturing company in Peru. We conducted business diagnostics and found a production efficiency problem. Later, we adapted the Lean production management model to the prevailing organizational culture. The main result was that the company's production efficiency increased from 68% to 71%. Finally, employee commitment, along with the combination of the Lean model and organizational culture, allowed the improvements to stand the test of time after their implementation.

In recent years, the giant squid processing industry in Peru exhibited a 59% increase in exports with respect to 2018. According to estimates, this industry generates approximately 30,900 jobs per year. However, some SMEs experience low productivity, such as the PECEPE company, due to plant downtime. This represents 26% of the available time, which translates into the loss of 1760 tons every year. The most constraining external factor the sector faces is uncertainty in resource availability caused by changing weather conditions and informal fishing activities. Although there is a large number of research studies on the fishing industry and resource extraction, literature on processing plant operations is scarce. Within this context, this study seeks to promote a high impact sector in Peru, as well as fostering processing plant competitiveness and productivity. Hence, to address these issues, the authors propose a maintenance management model under the TPM approach. As part of the results from model implementation, a 39% decrease was reported in plant downtime, while maintenance costs also decreased by 16%, which, in turn, increased machine availability and production by 784 tons per year.

Mislabeling of seafood is a global phenomenon that can misrepresent the status and level of consumption of wild fish stocks while concealing the use of many other wild species or those originating from aquaculture and sold as substitutes. We conducted a DNA barcoding study in three cities within Mexico (Mazatlan, Mexico City and Cancun) and sequenced the COI gene in 376 fish samples sold as 48 distinct commercial names at fish markets, grocery stores, and restaurants. Our goal was to identify the main species sold, their mislabeling rates and the species most used as substitutes. Overall, the study-wide mislabeling rate was 30.8% (95% CI 26.4–35.6). Half of the samples collected belonged to five species traded globally (yellowfin tuna, Atlantic salmon, mahi, swai, and tilapia), most of them with important aquaculture or ranching production levels. These species were commonly used as substitutes for other species and showed low mislabeling rates themselves (≤ 11%, except mahi mahi with 39% mislabeling). The other half of the samples revealed nearly 100 species targeted by small-scale fishers in Mexico and sold under 42 distinct commercial names. Popular local commercial names (dorado, marlin, mero, robalo, mojarra, huachinango, pargo, sierra) showed the highest mislabeling rates (36.3% to 94.4%) and served to sell many of the 53 species identified as substitutes in our study. We discuss the observed patterns in relation to landing and import data showing differences in availability of commercial species and the links to explain observed mislabeling rates and the use of a species as a substitute for other species. We also outline some of the implications of establishing a labeling and traceability standard as an alternative to improve transparency in the trade of seafood products in Mexico.

OBJECTIVE The authors sought to analyze a large, publicly available, nationwide hospital database to further elucidate the impact of cardiopulmonary arrest (CA) in association with subarachnoid hemorrhage (SAH) on short-term outcomes of mortality and discharge disposition. METHODS This retrospective cohort study was conducted by analyzing de-identified data from the National (Nationwide) Inpatient Sample (NIS). The publicly available NIS database represents a 20% stratified sample of all discharges and is powered to estimate 95% of all inpatient care delivered across hospitals in the US. A total of 170,869 patients were identified as having been hospitalized due to nontraumatic SAH from 2008 to 2014. RESULTS A total of 5415 patients (3.2%) were hospitalized with an admission diagnosis of CA in association with SAH. Independent risk factors for CA included a higher Charlson Comorbidity Index score, hospitalization in a small or nonteaching hospital, and a Medicaid or self-pay payor status. Compared with patients with SAH and not CA, patients with CA-SAH had a higher mean NIS Subarachnoid Severity Score (SSS) ± SD (1.67 ± 0.03 vs 1.13 ± 0.01, p < 0.0001) and a vastly higher mortality rate (82.1% vs 18.4%, p < 0.0001). In a multivariable model, age, NIS-SSS, and CA all remained significant independent predictors of mortality. Approximately 18% of patients with CA-SAH survived and were discharged to a rehabilitation facility or home with health services, outcomes that were most predicted by chronic disease processes and large teaching hospital status. CONCLUSIONS In the largest study of its kind, CA at onset was found to complicate roughly 3% of spontaneous SAH cases and was associated with extremely high mortality. Despite this, survival can still be expected in approximately 18% of patients.

Background: Arachnoid cysts (AC) may cause hydrocephalus and neurological symptoms, necessitating surgical intervention. Cyst drainage may result in postoperative complications, however, these interventions are not normally associated with the subsequent development of acute hydrocephalus. Herein, we present two unique cases of AC drainage with postoperative development of acute communicating hydrocephalus. Case Description: Case 1. A 75-year-old female presented with progressive headaches, cognitive decline, and questionable seizures. Her neurological examination was non-focal, but a head computed tomography scan (CT) identified a large right frontal AC with mass effect. She subsequently underwent craniotomy and decompression of the cyst. Postoperatively, her neurological examination deteriorated, and a head CT demonstrated new communicating hydrocephalus. The opening pressure was elevated upon placement of an external ventricular drain. Her hydrocephalus improved on follow-up imaging, but her neurological examination failed to improve, and she ultimately expired. Case 2. A 61-year-old female presented with headache and seizures attributed to a left parietal AC. She underwent open craniotomy for fenestration of the cyst into the Sylvian fissure. Postoperatively, her neurologic examination deteriorated, and she developed acute communicating hydrocephalus. She was initially managed with external ventricular drainage (EVD). The hydrocephalus resolved after several days, and the EVD was subsequently removed. Late follow-up imaging at 2 years showed that the regression of the AC was maintained. Conclusion: Acute development of hydrocephalus is a potential complication of intracranial AC fenestration. A better understanding of intracranial cerebrospinal fluid flow dynamics may better inform as to the underlying cause of this complication.

Objective A new automated and adjustable blood pressure (BP) system has been developed to improve the accuracy of BP measurements on public-use health stations. This self-fitting BP system includes a mechanical cuff that wraps down to the user’s arm prior to bladder inflation. The purpose of this study was to validate the adaptable BP system (ABPS) using the current standards from the Association for the Advancement of Medical Instrumentation (AAMI). Methods The AAMI/ISO 81060:2013 standards for clinical validation of non-invasive automated arterial BP measurement devices were followed precisely using the same arm sequential method. For each participant, BP was measured over multiple trials by trained observers alternating a reference sphygmomanometer with the ABPS. All study requirements were met with 85 qualifying participants, each with 3 valid paired determinations. Results The mean difference between ABPS BP and reference BP using all 255 paired determinations was −2.4 ± 7.7 mmHg for systolic and 1.7 ± 5.7 mmHg for diastolic. The standard deviation of the averaged paired determinations per participant was 6.3 mmHg for systolic and 5.2 mmHg for diastolic. Arm circumference measurements had a mean error of −2.1 ± 2.4 cm (R2 = 0.87). A new prediction model for arm circumference was validated using a holdout dataset (R2 = 0.94). Conclusion The results of the study confirm that the ABPS met all benchmarks established by the AAMI. The device accurately measures BP across a wide range of arm circumferences (24–44 cm) and is suitable for use by individuals to self-monitor BP.

A 70-year-old woman was admitted to the emergency department because of cardiogenic syncope and acute heart failure. She had a mechanical mitral prosthesis (MMP) (ATS Open Pivot 25 mm) implanted in August 2018, due to degenerative rupture of posterior leaflet. One month before admission anticoagulation was temporally interrupted due to humerus surgery. At admission, a transthoracic echocardiogram demonstrated a significant increase in MMP gradient with preserved ejection fraction and a pulmonary artery pressure of 50mmHg. To improve the assessment of MMP a transesophageal echocardiogram (TEE) was performed showing a restricted mobility of the mitral anterior prosthetic lens and a complete block of the mitral posterior lens leading to a severe mitral stenosis (mean pressure gradient 21 mmHg, peak pressure gradient 34 mmHg and peak velocity 2.9 meters/second) with a CW pattern that simulate an aortic morphology (Image 1A). MMP three-dimensional (3D) images were processed using a dedicated transillumination technology that uses a freely movable virtual light to enhance image details and depth (Image 1B and 1C). This rendering tool allows us to characterize tissue consistency and boundary delimitation, confirming the presence of a large thrombus that surrounded the entire posterior region of the prosthetic ring leading to a MMP 3D effective area of 0.49 cm2. After discussing the case with the valvular Heart Team an urgent surgery was performed to replace MMP. This case shows how the transillumination rendering tools enhance specific image features in prosthetic cardiac valves in critical clinical scenarios as symptomatic MMP thrombosis. Abstract P1463 Figure. Image 1

Background CHA2DS2-VASc score has been used as a surrogate marker for predicting outcomes beyond thromboembolic risk in patients with atrial fibrillation (AF). Likewise, cardiac troponin I (cTnI) is a predictor of mortality in AF. Purpose This study aimed to investigate the association of cTnI and CHA2DS2-VASc score with long-term prognosis in patients admitted to the emergency department with AF. Methods A retrospective cohort study conducted between January 2012 and December 2013, enrolling patients admitted to the emergency department with AF and having documented cTnI measurements. CHA2DS2-VASc score was estimated. Primary endpoint was 5-year all-cause mortality, readmission for heart failure (HF), readmission for myocardial infarction (MI) and the composite end point of major adverse cardiac events defined as death, readmission for HF or readmission for MI (MACE). Results A total of 578 patients with AF were studied, of whom 252 patients had elevated levels of cTnI (43.6%) and 334 patients had CHA2DS2-VASc score >3 (57.8%). Patients with elevated cTnI tended to be oldercompared with those who did not have cTnI elevation and were more frequently comorbid and of higher ischemic risk, including hypertension, prior MI, prior HF, chronic renal failure and peripheral artery disease. The overall median CHA2DS2-VASc score was higher in those with cTnI elevation compared to those patients elevated cTnI levels (4.2 vs 3.3 points, p Conclusions cTnI is independently associated with long-term all-cause mortality in patients attending the emergency department with AF. cTnI compared to CHA2DS2-VASc score is thus a biomarker with predictive capacity for mortality in late follow-up, conferring utility in the risk stratification of patients with atrial fibrillation.

Although groundwater is a major resource of water in the western US, little research has been done on the impacts of climate change on groundwater storage and recharge in the West. Here we assess the impact of projected changes in climate on groundwater recharge in the near (2021-2050) and far (2071-2100) future across the western US. Recharge is expected to decrease slightly (highly certain) in the West (−1.6%) and Southwest (−2.9%) regions in the near future and decrease considerably (highly certain) in the South region (−10.6%) in the far future. The Northern Rockies region is expected to get more recharge (highly certain) in both the near (+5.0%) and far (+9.0%) future. In general, southern portions of the western US are expected to get less recharge in the future and northern portions will get more. This study also shows that climate change interacts with land surface properties to affect the amount of recharge that occurs in the future.

The runner blade shape has been described as a set of discrete sections joining hub and shroud, resulting in such 3D free geometrical forms of considerable complexity that the search for an appropriate parametric approach for its reconstruction and optimization is still a matter of research field. For this reason, the main purpose of this study has been to reconstruct a real and twisted runner blade with a required accuracy through a methodology that uses several algorithms to combine sections and surfaces parametric approaches. Using the surface approach, the free-form shape of the 3D camber surface was defined by a multi-directional interpolation procedure. Using the section approach a Direct Profiling method was tested to fitting the hydrofoil section to the real one. For the blade reconstruction, ten profiles were stacked along the spanwise direction of the real blade to obtain by interpolation the pressure and suction sides using a lofting procedure, thus achieving an acceptable continuous and smooth surface definition. We assume that this methodology could be efficient to reconstruct a damaged and worn free-form blade, especially when the original surface geometry implies sections with different Thickness Distribution along the spanwise direction.

BackgroundThe discovery of potential disease-modifying therapies in a neurodegenerative condition like Huntington's disease depends on the availability of sensitive biomarkers that reflect decline across disease stages and that are functionally and clinically relevant.AimsTo quantify macrostructural and microstructural changes in participants with premanifest and symptomatic Huntington's disease over 30 months, and to establish their functional and clinical relevance.MethodMultimodal magnetic resonance imaging study measuring changes in macrostructural (volume) and microstructural (diffusivity) measures in 40 patients with premanifest Huntington's disease, 36 patients with symptomatic Huntington's disease and 36 healthy control participants over three testing sessions spanning 30 months.ResultsRelative to controls, there was greater longitudinal atrophy in participants with symptomatic Huntington's disease in whole brain, grey matter, caudate and putamen, as well as increased caudate fractional anisotropy; caudate volume loss was the only measure to differ between premanifest Huntington's disease and control groups. Changes in caudate volume and fractional anisotropy correlated with each other and neurocognitive decline; caudate volume loss also correlated with clinical and disease severity.ConclusionsCaudate neurodegeneration, especially atrophy, may be the most suitable candidate surrogate biomarker for consideration in the development of upcoming clinical trials.