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Purpose: To present a sling suture technique used to stabilize a collagen membrane against the lateral bone window to improve bone substitute stability inside the sinus cavity. Materials and Methods: Maxillary sinus floor augmentation was performed on 17 patients (8 women and 9 men; mean age 58.2 years) using a lateral approach with the sling suture technique to maintain a collagen membrane against the lateral bone window. Postoperative CBCT images were captured at 6-month follow-up of each patient to monitor the bone graft stability at the level of the lateral antrostomy. Clinical postoperative pain and swelling were assessed via visual analog scale (VAS) questionnaire, measured from level 1 (low) to level 5 (acceptable) to level 10 (high) at 1 week postoperative. Results: No bone substitute displacement was observed in any clinical cases on the CBCT images at 6 months postoperative. The pain and swelling levels observed 1 week postoperatively were significantly low (mean ± SD; 1.6 ± 1.0 and 2.1 ± 0.9, respectively). Conclusions: The use of the sling suture technique to maintain a barrier membrane at the level of the lateral bone window in cases of maxillary sinus floor augmentation using a lateral approach is a predictable protocol to prevent bone substitute displacement outside the sinus cavity. [ABSTRACT FROM AUTHOR]

Tooth extractions can result in alveolar bone dimensional changes, necessitating additional bone grafting for implant placement. Alveolar ridge preservation (ARP) aims to counteract postextraction changes. This case series evaluates the bone regenerative properties of a freeze-dried bone allograft (FDBA) and the clinical outcomes of implants in grafted extraction sites. A total of 33 patients were enrolled, undergoing single/multiple tooth extractions followed by ARP. Biopsy samples were harvested during implant placement for histologic and histomorphometric analysis. Clinical outcomes included marginal bone loss and pink esthetic score (PES). Twenty-five patients completed the study. FDBA-augmented sockets exhibited new bone formation adjacent to graft particles. Implants (n = 25) showed 100% survival and success rates at 1 and 2 years. PES improved significantly over time (P < .001), while marginal bone loss did not significantly differ at 1 and 2 years (P = .096). Specimens showed trabecular bone, residual FDBA particles, and marrow spaces. High magnification revealed immature bone and woven bone bridges around graft particles. No inflammatory cells were observed. This case series provides valuable insights into ARP performed with FDBA (as implants were placed after 3 months of healing without any additional bone augmentation), the histologic outcomes were favorable, and implants were successful after a 2-year follow-up period. [ABSTRACT FROM AUTHOR]

Introduction: Rectus sheath blocks have been used for decades in the operating room for analgesia following umbilical surgical procedures. We present the first reported case series of a rectus sheath block used in the emergency department (ED) for the reduction of an umbilical hernia.Case Series: Four patients presented to the ED for painful, non-reducible umbilical hernias. An ultrasound-guided bilateral rectus sheath block was used in all four patients with complete pain relief and an easy hernia reduction.Conclusion: Rectus sheath blocks are an excellent addition to a multimodal analgesic regimen in periumbilical pain and painful procedures. This block is easy to perform and implement for pain control in umbilical hernias in an ED setting.

BACKGROUND: Superior Semicircular Canal Dehiscence (SSCD) is a dehiscence of the otic capsule which normally lies over the superior semicircular canal. This database constitutes the largest series of SSCD patients to date. OBJECTIVE: To determine what preoperative factors, if any, contribute to postoperative outcomes and evaluate symptom resolution in a large SSCD patient cohort. METHODS: A single-institution, retrospective chart review collected patient demographics, intraoperative findings, and pre-and postoperative symptoms. Fishers exact t-test was performed for unpaired categorical variables, with a significance level of p

Context: The medial collateral ligament is the most commonly injured ligament in the knee. The high-speed pivoting and agility movements that are common in the sport of American Football put participants at an increased risk for a valgus force stress from contact or noncontact injuries. Positional release therapy (PRT) also considered strain/counterstrain focuses on releasing the tension in a tissue through unloading the involved body part. Case Presentation: Two male student-athletes participating in football with a mean age of 20.5 years were diagnosed by a physician with medial collateral ligament grade 2 sprain. Both patients sustained their injuries in a regular season game with a contact valgus force from an opposing player. Management and Outcomes: After the initial 72 hours of compression, elevation, and cryotherapy, the patients were both treated with PRT followed by progressive loading exercises. Following 4 treatment sessions of PRT over the next 6 days, the patients started with quadriceps engagement exercises, single-leg squats to 60° knee flexion, side steps, triceps dips, slow controlled lunges, and toe walk. The patients progressed to full body weight squats, single-leg landing, step-up tri-extension, and sidekicks with a leg on table. Then, the patients completed function movements and sports-specific exercises. Conclusions: In this case series, 2 patients competing in intercollege American Football were treated with PRT and progressive loading exercises to facilitate return to unrestricted activities and improve outcome measures. Commonly, a grade 2 medial collateral ligament sprain is conservatively treated with return to sport taking 20 days on average. In this type 2 case series, the clinician found success utilizing PRT early in the recovery process, which in these 2 cases lead to restoration of function, outcome measure improvement, and an expedited return to sport. The expedited return to sport occurred at an average of 18 days for these patients. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Objectives Patients and Methods Results Conclusions Octylisothiazolinone (OIT; CAS 26530–20‐1) is used as a biocide in leather products.To report several cases of allergic contact dermatitis (ACD) from the use of headphones containing OIT, and to highlight the strong allergic potential of this preservative.Four patients with ACD from headphones were patched tested using the European baseline, cosmetic, rubber, plastics/glues and acrylates series. Patients were also tested to different parts of their own headphones (‘as is’). Chemical analyses of the headphones was additionally performed with Ultra Performance Liquid Chromatography—tandem mass spectrometry (UPLC‐MS/MS).All patients had developed localised ACD to the contact sites of the headphones, except for one patient who developed ‘angioedema‐like’ dermatitis. All patients were shown to have been primarily sensitised to OIT. UPLC‐MS/MS analysis confirmed OIT in the leather ear pads of the headphones.OIT is a relevant and strong sensitizer in leather, and may cause severe ACD. Safer use concentrations (limits) of OIT, as well as product labelling in the leather industry, may be required to ensure a better protection of consumers. [ABSTRACT FROM AUTHOR]

Background: The resection of tumors of the proximal fibula includes the removal of the lateral collateral ligament (LCL) and biceps femoris tendon (BFT) attachment. The aim was to describe and evaluate a surgical reconstruction technique in terms of functional outcome and knee joint stability. Methods: We analyzed the outcome of six patients, treated by a proximal fibula resection. The reconstruction of the attachments of the LCL and BFT was performed with two suture anchors, fixed onto the tibia at the level of the proximal tibiofibular joint (PTFJ). The postoperative knee flexion strength as well as the lateral knee joint stability were compared to the contralateral side using a digital scale and stress X-ray. Patient-reported outcome measures and postoperative complications were documented. Results: No lateral instability and no significant loss of knee flexion strength could be observed (p = 0.075). One persistent postoperative peroneus paresis was reported. High functional outcome was achieved with a mean MSTS score of 92.2%. Conclusions: The resection of the proximal fibula with the reinsertion of the LCL and the BFT using bone anchors in the PTFJ seems to provide a good functional outcome, with a low level of associated comorbidities. [ABSTRACT FROM AUTHOR]

Treatment priority in C5, C6, and C7 brachial plexus root avulsion is the recovery of shoulder function through reinnervation of shoulder muscles. The medial pectoral nerve is a potential donor for axillary nerve transfer, but outcomes are sparsely reported. This study reports the results of medial pectoral nerve transfer to the axillary nerve. We conducted a retrospective analysis of 12 patients with traumatic brachial plexus injury (C5, C6, and C7 root avulsion) who underwent medial pectoral nerve transfer to the axillary nerve. Sociodemographic and clinical characteristics, including electromyography findings, were documented. We assessed postoperative shoulder abduction strength and range of motion. Statistical analyses compared presurgery and postsurgery outcomes and contrasted our results with those from a study using spinal accessory nerve transfer to the suprascapular nerve. Postsurgery, the mean shoulder abduction range of motion was 65.45°, with a median strength of M2. Significant improvement was noted compared to preoperative values. However, outcomes did not significantly surpass those from spinal accessory nerve transfer. Electromyography showed a low incidence of motor unit action potentials in the deltoid. Medial pectoral nerve transfer to the axillary nerve did not yield superior results in shoulder abduction and deltoid reinnervation in our group of patients. At present, different nerve donors may also need to be considered for deltoid muscle reinnervation in patients with C5, C6, and C7 root avulsion to achieve better shoulder abduction recovery. [ABSTRACT FROM AUTHOR]

Background: There have been few reports of a totally extraperitoneal approach for laparoscopic lateral lymph node dissection (LLND) for patients with metachronous lateral pelvic lymph node metastases following surgery for rectal cancer. Therefore, this study reports the short-term outcomes of LLND via an extraperitoneal approach. Methods: A total of 10 patients underwent LLND through a laparoscopic extraperitoneal approach in our hospital since October 2018. Patients with suspected resectable lateral lymph node recurrence after surgery for rectal cancer on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography CT (PET-CT) were selected for this procedure. Results: Nine of the 10 cases were completed using this procedure, but one case was converted to an intraperitoneal approach. The median operative time was 231 min, and the median estimated blood loss was 10 ml. There was one case of wound infection, but no other postoperative complications were seen. In one patient, no metastases were found in the retrieved lymph nodes. Conclusion: The short-term outcomes of LLND through a laparoscopic extraperitoneal approach were acceptable. Because this procedure can be performed without violating the peritoneum, it is less invasive than the conventional intraperitoneal approach and is useful for metachronous lateral pelvic lymph node metastases. [ABSTRACT FROM AUTHOR]

COVID-19-associated cerebellar ataxia has rarely been reported and its clinical characteristics remain understudied. This study aims to report patients with COVID-19-associated cerebellar ataxia from our institution. COVID-19-associated cerebellar ataxia was diagnosed based on the prodromal COVID-19 infection and the exclusion of other causes. This study provides a summary of the patients' clinical presentations, neuroimaging features, and the results of anti-cerebellar antibody examinations. Our study included 11 patients and 4 were male. The median onset age was 38 years. Five patients also demonstrated signs of encephalopathy. Brain magnetic resonance imaging (MRI) was either unremarkable (n = 6) or showed bilateral cerebellar lesions (n = 5), which were typically transient, although brain atrophy could be observed later in the disease course. Anti-Homer-3 and anti-Yo antibodies were each detected in one patient, respectively. All patients received immunotherapy and nine improved. Compared with the late-onset group, individuals who exhibited ataxia earlier following COVID-19 onset (interval<5 days) were significantly younger [median age 18 (15.5–31) vs. 53.5 (44-64.8) years, p = 0.009] and more likely to present with encephalopathy (5/5 vs. 0/6, p = 0.002).They also experienced more severe symptoms [median modified Rankin scale (mRS) score at zenith 5 (5–5) vs. 2 (1.75–2.75), p = 0.017] and had a less favorable prognosis [median mRS score at the last follow-up 4 (2–5) vs. 1 (0-1.25), p = 0.009]. COVID-19-associated cerebellar ataxia can appear with encephalopathy. Brain MRI may show transient bilateral cerebellar lesions and brain atrophy later. Patients who exhibited ataxia earlier following COVID-19 were younger, had more severe symptoms and poorer outcomes. [ABSTRACT FROM AUTHOR]

"Subureteric Teflon INGection" (STING) of polytetrafluoroethylene (PTFE/polytef) paste to treat vesicoureteral reflux (VUR) in children was popularised in 1984. It was later abandoned as an implantation material because of the possibility of migration from the injection site. Giant-cell foreign-body granuloma to Polytef in the bladder is a rare cause of ureteric obstruction. Only a handful of cases have been reported in the literature. We performed a prospective analysis of a series of 6 adult patients who had childhood STING and presented with foreign-body granuloma to Polytef in the bladder. We report their clinical presentation, findings and treatment. 1 male and 5 females with a history of STING procedure in childhood for VUR presented in later life with foreign-body granuloma to Polytef. The median age at first STING procedure and at presentation to the Urology Department was 3 and 34 years respectively. The most common clinical presentations were flank pain and urinary tract infection (UTI) and all patients had radiological findings of calcified lesions at the vesicoureteric junction(s). 4 patients had histological findings of giant-cell foreign-body granuloma. 4 patients required definitive ureteric reimplantation. Polytef granuloma causing distal ureteric obstruction may give rise to significant morbidity and renal damage. Due to the likelihood of progression of the granuloma, excision and ureteric reimplantation is considered the standard approach in the management of patients with viable kidneys. Level 5. • Subureteric injection with Teflon was used to treat vesicoureteric reflux in children • Teflon granulomas can cause delayed complications >30 years after surgery • Complications include ureteric obstruction or non-functioning kidneys • These may require treatment by surgical techniques such as ureteric reimplantation [ABSTRACT FROM AUTHOR]

Objective: Temporal lobe encephaloceles (TLEN) have been implicated as a cause of temporal lobe epilepsy (TLE), the treatment which is primarily surgical; however, there is no clear consensus on the optimal surgical approach, because it is unclear whether TLE related to TLEN can be addressed by a restricted encephalocele resection or if a more extensive resection is required. The aim of the current article is to report the clinical and electrophysiological profile of patients with TLE secondary to TLEN who underwent stereotactic electroencephalography (SEEG) implantation to identify the epileptogenic network. Methods: A retrospective review was performed of patients with TLE related to TLEN who underwent SEEG implantation. Medical charts were reviewed for demographic data, the results of noninvasive and invasive investigations, and operative details. Surgical outcomes were based on Engel classification with at least 6 months follow‐up. Results: Nine patients were identified. The mean age at epilepsy onset was 28 years (range, 15–41 years), and 7/9 patients were female. Scalp EEG revealed interictal epileptiform activity most often maximum in the frontotemporal and/or temporal regions. A discrete TLEN was often not identified on initial imaging, but was identified during re‐review or at the time of surgery. Seizure onset zones during SEEG were localized to the mesial temporal structures, the temporal pole, or both. One patient became seizure‐free following SEEG and another refused further surgery. Of the 7 patients who underwent epilepsy surgery, 5/7 underwent an anterior temporal lobectomy—surgical outcomes were favorable, with 5/7 achieving Engel I outcomes. Significance: Invasive SEEG monitoring demonstrated ictal onsets may not be restricted to the TLEN, and often the temporal pole and mesial structures are involved at seizure onset. Ictal propagation patterns vary significantly, which may be related to the underlying pathology and explain the variability in semiology. These findings may inform surgical treatment options. Plain language summary: Temporal lobe encephaloceles can cause intractable epilepsy, although their presence may be missed on routine imaging. The management of encephaloceles is primarily surgical; however, the optimal surgical approach can be unclear. Invasive monitoring with SEEG may help characterize the epileptogenic network and result in more optimal surgical outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Aortic graft infection (AGI) is a rare complication following endovascular aneurysm repair and is associated with substantial morbidity and mortality. The traditional management of AGI is intravenous antibiotic therapy and surgical explantation. In this case series, percutaneous drainage was used as a bridge therapy in the treatment of AGI. Methods: We report two cases, 78-year-old male and 57-year-old female, in whom image-guided percutaneous drainage was used to treat AGI in two contrasting contexts. Informed consent was obtained from both cases/relatives for publication. Results: Both cases underwent successful percutaneous drainage of AGI utilized as a bridge therapy before definitive surgical reconstruction and graft explantation. Each patient had a different outcome. In the first case, the patient's comorbidities and severe disease state could not be overcome, resulting in his death. The second patient benefitted from the percutaneous drainage by allowing her more time ameliorate her malnutrition before definitive surgery. Conclusion: Data on the outcomes of percutaneous drainage of AGI is limited. The successful procedure described in this case series emphasizes the need to conduct more research to evaluate the safety and efficacy of this treatment approach before the surgical explantation. [ABSTRACT FROM AUTHOR]

Neuroendocrine tumors account for 0.5% of all malignancies, and their incidence is around 2/100,000 with a female predilection within the age range of 50 years at the time of presentation. NETs in India have a different clinicopathological profile compared to those in Western countries. Very few limited studies are available in Indian literature with regard to the epidemiology, presentations, histopathological characteristics, and treatment outcomes in patients with gastrointestinal neuroendocrine tumors. This warrants the need for documentation of these tumors, and we hereby present a case series of four patients diagnosed with NETs who presented within a period of 9 months at our rural tertiary care center. [ABSTRACT FROM AUTHOR]

Background: The case fatality rate of untreated dengue is 20%; it can be reduced to less than 1% with optimal management. The leading causes of death in dengue patients are shock, bleeding, and acute liver injury. We describe the clinical features of patients who died of dengue and discuss the therapeutic challenges and pitfalls of complicated dengue. Methods: This retrospective study was done in the intensive care unit (MICU) of the National Hospital of Sri Lanka over 30 months between 2021 and 2023. All patients who died of serologically confirmed dengue were incorporated. Results: Of the 1722 ICU admissions, 44 (2.6%) patients were treated for dengue—of them, 11 (25.0%) died. Two patients were excluded as their deaths were not directly linked to dengue. Six were females. The average age was 40.2 years. The leading causes of death included shock (n = 5), acute liver failure (n = 6), intracranial bleeding (n = 2), and pulmonary embolism (n = 1). Patient 1 had concomitant leakage and bleeding, which did not respond to fluids or blood products. He developed fluid overload and acute liver failure (ALF) and died of multiorgan dysfunction. Patients 2–5 were in shock for a prolonged period due to leakage ± bleeding. Patients 2–5 developed ALF and lactic acidosis followed by multiorgan dysfunction. Patient 8 developed acute hepatitis and ALF without preceding shock. The patient was treated with immunosuppressants for myasthenia gravis. Patients 6 and 7 experienced intracranial bleeding. Patient 9 died of pulmonary embolism after prolonged ventilation for dengue encephalitis. Conclusions: Prolonged shock, fluid overload and acute liver failure were common causes of dengue related deaths, in our study. Fluid overload occurred when vigorous crystalloid resuscitation was continued in patients who were poorly responding. A prompt switch to colloids or blood could have prevented overload. Patients who were in shock for a prolonged period become unresponsive to fluid resuscitation. How to manage dengue in patients who take anti-inflammatory drugs, immunomodulators, or antiplatelets is not known. Balancing the bleeding risk of dengue in patients predisposed to bleeding or thrombosis is a challenge. [ABSTRACT FROM AUTHOR]

An expansion in the availability of generic specialty disease modifying therapies (DMTs) for treatment of multiple sclerosis (MS) has increased recently. Generic specialty medications aim to provide greater access to molecules that alter the disease trajectory at lower costs. The US Food and Drug Administration requires generic products to contain between 90% and 110% of the stated active ingredient and an 80%–125% bioequivalence range. We present the clinical experiences and absolute lymphocyte counts (ALC) trends of six people with MS originally treated with Gilenya® (fingolimod) 0.5 mg who were required to transition to generic fingolimod 0.5 mg by third-party administrators, and the medication content from recovered products. Six individuals with acute clinical exacerbations or disease advancement on MRI were identified during routine scheduled visits from a tertiary care center and consecutively included from January 2024 to August 2024. ALC trends were constructed for each individual during Gilenya® and generic fingolimod treatment. These individuals experienced signs of disease advancement while on generic fingolimod 0.5 mg at approximately 1 year of treatment and elevations in ALC, a biological metric related to the mechanism of action of sphingsine-1-phosphate receptor modulation, were observed following the transition. High purity fingolimod for standardization tests, Gilenya® 0.5 mg, and five recovered generic fingolimod 0.5 mg products were independently tested in an accredited laboratory. Gilenya® 0.5 mg capsules had an average fingolimod content of 97.7% (standard deviation (SD) = 2.59%). Three recovered generic fingolimod 0.5 mg products used during relapses had an average content of 91.2% (3.25%), 81.6% (6.24%), and 72.5% (2.05%). Two generic fingolimod 0.5 mg products not associated with relapse activity revealed averages of 97.4% (1.82%) and 103.3% (3.77%). Subpotent generic specialty DMTs may not only result in greater risk for disease activity but may also expose individuals to the potential for disease rebound, depending on the mechanism of action. [ABSTRACT FROM AUTHOR]

Tuberculous meningitis (TBM) has considerable mortality and morbidity, and it often presents therapeutic challenges when complicated by paradoxical reactions (PRs). Here, the clinical course of four cases of TBM patients complicated by PRs in a longitudinal TB cohort is described while also providing insights from the larger clinical cohort. Research flow cytometry, biomarker analysis, and drug concentrations were performed on available samples. All participants were initiated on standard antituberculosis therapy (ATT) and enrolled at the onset of PRs (PR group) or 2–4 months after the start of ATT (controls). The four TBM participants highlighted here presented with fevers, headaches, neurological deficits, and fatigue at the initial presentation. Upon diagnosis, all were initiated on rifampin, isoniazid, pyrazinamide, and ethambutol (RHZE) at standard doses and on corticosteroids. The median time to first PR was 37 days with recrudescence of initial TBM signs and symptoms at the time of PR. At the time of referral, all participants had low drug concentrations requiring dose optimization and regimen intensification as well as recrudescent flares upon corticosteroid taper, with one individual developing enlargement of tuberculoma 1 year following completion of ATT. Based on biomarkers and flow cytometry, PRs are characterized by elevated interferon-gamma and ferritin levels in the plasma compared to controls. In the TBM participants, T-cell activation with elevated levels of inflammatory biomarkers in the cerebrospinal fluid (CSF) was seen at the time of PR. These unique and highly detailed TBM cases provide insights into the pathogenesis of PRs, which may assist with future diagnostics and treatment. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Changes in gastrointestinal physiology following bariatric surgery may affect the pharmacokinetics of drugs. Data on the impact of bariatric surgery on drugs used for attention‐deficit/hyperactivity disorder (ADHD) are limited.In patients treated with ADHD medication and undergoing bariatric surgery, serial drug concentrations were measured for 24 h preoperatively and one, six and 12 months postoperatively. Primary outcome was change in area under the concentration‐time curve from 0 to 24 h (AUC0–24), with other pharmacokinetic variables as secondary outcomes.Eight patients treated with lisdexamphetamine (n = 4), dexamphetamine (n = 1), methylphenidate (n = 1) and atomoxetine (n = 2) were included. In total, 409 samples were analysed. Patients underwent sleeve gastrectomy (n = 5) and Roux‐en‐Y gastric bypass (n = 3). AUC0–24 and Cmax of dexamphetamine increased after surgery in those using the prodrug lisdexamphetamine. There was no clear‐cut reduction in tmax postoperatively. For ritalinic acid and atomoxetine, no changes in AUC0–24 were observed, but for atomoxetine, a higher Cmax and a shorter tmax were observed postoperatively.Bariatric surgery may increase the systemic exposure of dexamphetamine after intake of lisdexamphetamine. Patients using lisdexamphetamine should be followed with regard to adverse drug reactions after bariatric surgery, and, if available, therapeutic drug monitoring should be considered. [ABSTRACT FROM AUTHOR]

Introduction: A supraorbital keyhole craniotomy (SOKC) is a novel alternative to frontal craniotomies for accessing the anterior fossa for resecting tumors and clipping aneurysms; however, its implementation is limited in patients at a high risk of complications. We present two cases involving the use of augmented reality (AR) and virtual reality (VR) for patient selection and preoperative planning for a supraorbital tumor resection of anterior fossa meningiomas. Methods: This is a prospective, single-center case series at a research institute. We identified patients with an anterior or middle fossa meningioma regardless of age, gender, and tumor characteristics who could undergo an SOKC and MRI. The preoperative planning was performed with the BrainLab Magic Leap AR/VR platform. The meningiomas were resected through the SOKC under neuronavigation. Results: We identified two cases: a 37-year-old male with a meningioma in the sellar region and an 84-year-old male with a right anterior fossa meningioma, both confirmed by MRI. Both patients had a complete tumor resection by a minimally invasive SOKC after preoperative planning with the AR/VR platform. Postoperatively, hyponatremia complicated the first case, while the second case developed an intracranial hemorrhage. They both recovered after the appropriate interventions. Conclusions: The use of an SOKC for anterior skull base meningiomas should be individualized after considering the lesion characteristics, vascular control needs, and the surgeon's expertise. VR/AR-assisted preoperative evaluation and planning will optimize the patient selection and surgical outcomes. We can utilize VR/AR technologies to identify patients that will benefit from an SOKC and expand the implementation of the approach beyond its current limitations. [ABSTRACT FROM AUTHOR]

OBJECTIVE To describe the treatment of subcutaneous lipomas in the horse. ANIMALS 3 horses. CLINICAL PRESENTATION The horses were aged 1 to 2 years old, with lipomas of the abdomen, prepuce, and tarsus. RESULTS All cases had surgical removal of the masses under general anesthesia. Recurrence of an invasive abdominal lipoma occurred In case 1 at the exit site of a passive drain. The recurrence was treated unsuccessfully with Injectable cispla-tin, and a second revision surgery with the use of an active drain resulted In resolution. In case 2, complete resection of an encapsulated lipoma of the lateral prepuce was successful with no recurrence. In case 3, Incomplete resection of a tarsal lipoma resulted In a sound horse, with no further growth. Histopathologic analysis revealed that all masses were composed of well-differentiated adipocytes with no evidence of malignancy. CLINICAL RELEVANCE Subcutaneous lipomas are relatively rare and affect horses primarily < 2 years of age. They are benign, although their presence can be deleterious due to Invasion of local structures or the impact on normal locomotion. The margins of Invasive tumors are difficult to Identify due to their integration with normal tissue. Incomplete removal may allow for mass recurrence. Active suctions drains are beneficial if dead space Is a concern. [ABSTRACT FROM AUTHOR]

Key Clinical Message: We report three cases of IMN from our center, where patients received a single dose of telitacicept after showing no response to conventional treatments. Although one case did not respond, the other two cases achieved complete or partial remission of proteinuria. These cases illustrates the telitacicept may offer new hope for the treatment of IMN. Despite the variety of treatment options available, effective therapies for refractory membranous nephropathy remain lacking. Recently, some reports have suggested that telitacicept is a new therapeutic option. However, only a few published studies have documented the use of telitacicept for treating idiopathic membranous nephropathy (IMN). We present three cases of IMN from our center, where patients received a single dose of telitacicept after showing no response to conventional treatments, including glucocorticoids, tacrolimus, mycophenolate mofetil, cyclophosphamide, cyclosporine, and rituximab. Although one case did not respond, the other two cases achieved complete or partial remission of proteinuria. Thus, telitacicept may offer new hope for the treatment of refractory membranous nephropathy. [ABSTRACT FROM AUTHOR]

Introduction: Hyperactive catatonia is often unrecognized in pediatric patients due to its clinical heterogeneity, though it is often seen in children with neurodevelopmental disabilities, especially autism spectrum disorder (ASD). Emerging evidence implicates hyperactive catatonia in more cases of self-injury and aggression in ASD than previously thought. Objectives: The study seeks to describe cases of hyperactive catatonia in SYNGAP-1 mutation and examine existing literature for symptomatic overlap between previously-described clinical and behavioral phenotypes of individuals with SYNGAP-1 mutations and catatonia. Methods: The study describes two cases of an adolescent and a young adult with SYNGAP-1 mutation and ASD presenting with hyperactive catatonia, which are the first reports of catatonia in individuals known to have a pathogenic variant in SYNGAP-1. A systematic review was undertaken during which 101 articles were screened. 13 articles were then examined for neurological and behavioral features present in participants with SYNGAP-1 mutations which are seen in catatonia. Results: The systematic review demonstrates that clinical features suggestive of catatonia are frequently seen among individuals with SYNGAP-1 mutations, including verbal impairment, psychomotor symptoms, aggression, oral aversion, and incontinence. These features were also present in the cases of catatonia in SYNGAP-1 mutations presented here. Both patients showed clinical improvement with use of a long-acting benzodiazepine, and one patient showed benefit from electroconvulsive therapy. Conclusions: This symptomatic overlap revealed in the systematic review, including symptoms seen in the reported cases, raises the possibility that diagnoses of catatonia may have been missed in the past in individuals with SYNGAP-1 mutations. Self-injurious behavior and aggression, which are hallmarks of hyperactive catatonia, are commonly part of the behavioral phenotype of SYNGAP-1-related disorders. Clinicians should consider catatonia as a cause of such symptoms in individuals with SYNGAP-1 mutations, as effective treatment can result in significant improvement in safety and quality of life. [ABSTRACT FROM AUTHOR]

Catatonia is a neuropsychiatric syndrome that is an increasingly recognized cause of acute behavioural changes in children and adolescents with neurodevelopmental disorders (NDD). Literature suggests that catatonia can present differently in this population and can be missed due to diagnostic overshadowing. Catatonia is a treatable condition, and management strategies in children with NDD include benzodiazepines and electroconvulsive therapy (ECT). Untreated, it can cause significant morbidity including severe medical complications, and therefore timely recognition and management of catatonia in children and adolescents with NDD is essential. In this case series, we present three cases of children ages 7, 14, and 10, with diagnoses of autism spectrum disorder, Down syndrome, and Prader-Willi syndrome, respectively. All were admitted to a pediatric inpatient unit for acute behavioural regression. Each had symptoms consistent with catatonia, resulting in trials of benzodiazepine therapy with inadequate response, and were then treated with bilateral ECT. In all cases, marked improvement was noted after ECT, with no apparent adverse effects. The cases are used to highlight the nuances of diagnosis and management of catatonia in children and adolescents with NDD. This includes insights on how presentations of catatonia may differ in this population, challenges with the use of available diagnostic tools, and how these patients may respond differently to recommended treatments such as benzodiazepines. The case series aims to increase clinicians' awareness of pediatric catatonia when children and adolescents with NDD present with acute behavioural changes, and to encourage consideration of the full spectrum of treatments, including bilateral ECT. [ABSTRACT FROM AUTHOR]

Introduction: Myelomeningocele (MMC) is the most common neural tube defect, but rarely seen in premature infants. Most centers advocate for closure of MMC within 24 h of birth. However, this is not always possible in severely premature infants. Given the rarity of this patient population, we aimed to share our institutional experience and outcomes of severely premature infants with MMC. Methods: We performed a retrospective, observational review of premature infants (≤ 32 weeks gestational age) identified through our multidisciplinary spina bifida clinic (1995–2021) and surgical logs. Descriptive statistics were compiled about this sample including timing of MMC closure and incidence of adverse events such as sepsis, CSF diversion, meningitis, and death. Results: Eight patients were identified (50% male) with MMC who were born ≤ 32 weeks gestational age. Mean gestational age of the population was 27.3 weeks (SD 3.5). Median time to MMC closure was 1.5 days (IQR = 1—80.8). Five patients were taken for surgery within the recommended 48 h of birth; 2 patients underwent significantly delayed closure (107 and 139 days); and one patient's defect epithelized without surgical intervention. Six of eight patients required permanent cerebrospinal fluid (CSF) diversion (2 patients were treated with ventriculoperitoneal shunting (VPS), three were treated with endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) and 1 patient treated with ETV; mean of 3 years after birth, ranging from 1 day to 16 years). Two patients required more than one permanent CSF diversion procedure. Two patients developed sepsis (defined as meeting at least 2/4 SIRS criteria). In both cases of sepsis, patients developed signs and symptoms more than 72 h after birth. Notably, both instances of sepsis occurred unrelated to operative intervention as they occurred before permanent MMC closure. Two patients had intraventricular hemorrhage (both grade III). No patients developed meningitis (defined as positive CSF cultures) prior to MMC closure. Median follow up duration was 9.7 years. During this time epoch, 3 patients died: Two before 2 years of age of causes unrelated to surgical intervention. One of the two patients with grade III IVH died within 24 h of MMC closure. Conclusions: In our institutional experience with premature infants with MMC, some patients underwent delayed MMC closure. The overall rate of meningitis, sepsis, and mortality for preterm children with MMC was similar to MMC patients born at term. [ABSTRACT FROM AUTHOR]

This article discusses the use of SCINSEV measures in cochlear implant surgery to detect and correct electrode extrusion. The study presents three cases where SCINSEV was used to identify extrusion and make immediate surgical corrections, eliminating the need for revision surgery. The authors suggest that SCINSEV, along with other measures, can improve the efficiency and outcomes of cochlear implant surgery by reducing the reliance on x-rays and the need for revision surgery. The article provides detailed information on the methodology and results of the study, highlighting the potential of SCINSEV as an important tool in intraoperative decision-making and correction. [Extracted from the article]

Background Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome (ACS). Various factors predispose individuals to SCAD, including coronary vasospasm, which has been identified in some studies as a related factor. Case summary We present a series of three cases of ACS attributed to SCAD. Two cases involved early de novo recurrence potentially related to coronary spasm, and one case involved iatrogenic coronary artery dissection during a spasm provocation test. Discussion High recurrence rates of SCAD within 30 days of the initial event have been observed, although the effectiveness of pharmacologic therapy has not been conclusively established. While the administration of beta-blockers has been associated with a reduced risk of SCAD recurrence, their use may not be desirable in patients with coronary vasospasm. Detailed evaluations may be beneficial for patients where coronary vasospasm is suspected to tailor appropriate treatment strategies. Moreover, given the higher frequency of iatrogenic coronary artery dissection among patients with SCAD, careful consideration is needed to avoid high-risk periods when scheduling spasm provocation tests. [ABSTRACT FROM AUTHOR]

Direct visualization of the eye can be difficult or impossible when there is significant facial burns, trauma, or edema. We present 4 nonresponsive, critically ill children whose pupils could not be directly visualized. Ophthalmic ultrasound revealed pupillary reactivity at presentation and throughout their recovery. Determining pupillary reactivity in these nonresponsive patients impacted their initial triage, resuscitation, and medical management. We propose that ophthalmic point‐of‐care ultrasonography can assess the pupillary light reflex in critically ill children whose pupils cannot be directly visualized. [ABSTRACT FROM AUTHOR]

Kikuchi–Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare, self-limiting disorder characterized by fever typically lasting for 1 week up to 1 month and painful necrotizing lymphadenopathy, primarily affecting young adults of Asian ancestry. Although the exact cause remains unclear, infectious and autoimmune mechanisms have been implicated in the pathogenesis of the disease. In this case series, we aim to describe the histopathological features of KFD over a ten-year period at Mount Sinai Medical Center of Florida, and review the current understanding of its pathogenesis, clinical presentation, diagnosis, and management. A retrospective review of our pathology database between January 2013 and May 2024 was performed to identify patients diagnosed with KFD at our institution. Eight cases of KFD were identified, with a mean age of 35 years (range 24–49) and slight male predilection (5:3). Three patients exhibited leukopenia, and two had concurrent HIV infection. One patient developed systemic lupus erythematosus (SLE), and another developed IgA nephropathy during follow-up. Histopathological examination revealed the characteristic features of KFD, including lymph node architectural effacement, histiocytic infiltration, and necrosis. In conclusion, KFD remains a diagnostic challenge due to its overlapping clinical features with other infectious and autoimmune diseases, particularly SLE. While most cases resolve spontaneously, long-term follow-up is warranted due to the potential for recurrence and autoimmune associations. [ABSTRACT FROM AUTHOR]

Purpose: Following spinal fixation, postoperative imaging is routinely performed. The value of routine postoperative imaging and its impact on the surgical decision remains uncertain, especially in degenerative cases. Moreover, routine postoperative imaging is not free and is an ionizing radiation. This study investigated the value of postoperative imaging after uneventful uncomplicated elective posterior lumbar fixation. Methods: This case series retrospectively reviewed the medical records of patients who underwent elective posterior lumbar fixation surgeries at our institution within two years. A series of 98 cases met our selection criteria. Their mean age was 51.2 years. We reviewed the decisions taken after performing the routine postoperative images. We searched for further diagnostic or imaging studies, revision surgery, or an extended hospital stay. Results: We found no particular decision was made after performing the postoperative imaging after uneventful uncomplicated elective posterior lumbar fixation surgeries. Moreover, there was no change in the hospital stay or the regular postoperative clinical management for all the included patients. No revision surgery was required based on the postoperative routine images. Conclusions: We found that routine postoperative imaging after posterior fixation of a degenerative lumbar spine is of limited value. A randomized, controlled study is helpful to confirm this finding. [ABSTRACT FROM AUTHOR]

Background: Efgartigimod was approved in Japan in January 2022 for the treatment of generalized myasthenia gravis (gMG), regardless of antibody status. This case series describes a real-world experience in Japan of efgartigimod treatment for gMG patients with diverse backgrounds. Methods: We retrospectively analyzed the medical records of 16 Japanese patients (11 females and five males, mean age 40.4 years) with gMG who received efgartigimod at the Kumamoto University Hospital between August 2022 and September 2023. The outcomes were Quantitative Myasthenia Gravis (QMG) responders (= 3 point reduction), IgG levels, and change in prednisolone dose, in the first cycle of efgartigimod. Results: Fifteen patients completed one cycle of efgartigimod. Of the 14 patients for whom QMG scores were obtained, 10 patients were QMG responders. Four of the five patients with Myasthenia Gravis Foundation of America class V were QMG responders. Improvement in QMG after efgartigimod treatment was observed in one patient with myasthenic crisis and in one refractory patient who had unsuccessful eculizumab treatment. The mean reductions from baseline in IgG levels at weeks 1, 2, 3, and follow-up were 38.3, 56.1, 63.1, and 43.9%, respectively. A decrease in prednisolone dose was observed in seven patients. The most common adverse events were headache (three patients) and diarrhea (two patients). One patient discontinued efgartigimod treatment due to a treatment-related adverse event of rash. Conclusion: Improvements in the outcomes of patients with gMG, including patients with severe gMG, myasthenic crisis, and refractory to anticomplementary therapy, were observed after the first cycle of efgartigimod treatment. Our real-world experience in Japan suggests the future possibilities for the treatment with efgartigimod for gMG with diverse backgrounds. [ABSTRACT FROM AUTHOR]

Objective: Intraventricular baclofen has been reported as an alternative to intrathecal baclofen for managing refractory spasticity and dystonia in some circumstances. In this report, we described a frame-based stereotactic approach for precisely positioning of the infusion catheter into the third ventricle. Material and methods: High resolution contrast-enhanced anatomical MR sequences was acquired prior to surgery for pre-planning. Catheter trajectory was planned to pass from the lateral ventricle to the third ventricle through the Foramen of Monro. The surgical procedure was adapted from the frame-based deep brain stimulation surgery. The Touch-Loc kit (SceneRay, China) was used to temporarily secure the catheter in place during the surgery. From July 2022 to December 2022, three patients suffering from intractable spasticity and/or secondary dystonia received IVB successfully using the described technique. Results: No severe adverse events, including death, intracranial hemorrhage, infection, catheter migration or fracture, were documented at the last follow-up (range: 12‒24 months). Transient side effects included mild nausea following the initiation of infusion or the increase in infusion rate. All three patients responded to the IVB. Conclusions: The described frame-based stereotactic technique for IVB catheter implant is feasible and could be quickly mastered by neurosurgeons in related fields. Larger prospective cohorts with longer follow-up periods are necessary to further evaluate the long-term safety and efficacy of this procedure. [ABSTRACT FROM AUTHOR]

Summary Management of chemotherapy‐induced thrombocytopenia (CIT) is challenging, often resulting in chemotherapy treatment delays, dose reduction, and treatment interruption. Randomized trials support the potential efficacy and safety of thrombopoietin receptor agonists in CIT management. A phase III trial of avatrombopag (AVA) demonstrated increased platelet counts (PC) in patients with solid tumours experiencing CIT. To complement those findings, this case series of six patients with solid tumours and CIT is presented. Results from these cases support the clinical benefit of AVA in improving PC and reducing the impact of CIT on tumour treatment, allowing continued therapy without dose reduction or treatment interruption. [ABSTRACT FROM AUTHOR]

Objective: The safety, feasibility, and potential functional improvement following the intravenous infusion of mesenchymal stem cells (MSCs) were investigated in patients with chronic severe spinal cord injury (SCI). Methods: The intravenous infusion of autologous MSCs cultured in auto-serum under Good Manufacturing Practices (GMP) was administered to seven patients with chronic SCI (ranging from 1.3 years to 27 years after the onset of SCI). In addition to evaluating feasibility and safety, neurological function was evaluated using the American Spinal Injury Association Impairment Scale (AIS), International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI-92), and Spinal Cord Independence Measure III (SCIM-III). Results: No serious adverse events occurred. Neither CNS tumors, abnormal cell growth, nor neurological deterioration occurred in any patients. While this initial case series was not blinded, significant functional improvements and increased quality of life (QOL) were observed at 90 and 180 days post-MSC infusion compared to pre-infusion status. One patient who had an AIS grade C improved to grade D within six months after MSC infusion. Conclusions: This case series suggests that the intravenous infusion of autologous MSCs is a safe and feasible therapeutic approach for chronic SCI patients. Furthermore, our data showed significant functional improvements and better QOL after MSC infusion in patients with chronic SCI. A blind large-scale study will be necessary to fully evaluate this possibility. [ABSTRACT FROM AUTHOR]

Background: Bone scintigraphy (BS) is established as an accurate, non-invasive method for the diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CM). In a real-life setting, however, some patients with no cardiac uptake on BS turn out to have cardiac-biopsy-confirmed ATTR-CM. We retrospectively included all patients diagnosed at the French Referral Center for ATTR-CM and who had data for BS and a cardiac biopsy. Results: Of 271 patients with positive cardiac biopsy, 14 (5%) had no cardiac uptake on 99mTc-hydroxymethylene diphosphonate BS. Cardiac uptake was found in four of the seven patients who had a second BS assessment with 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD). A retrospective review of the BS data found low cardiac uptake in four patients (two with HMDP and two with both radiotracers). Ultimately, six of the 14 patients with a biopsy-confirmed diagnosis of ATTR-CM did not show any cardiac radiotracer uptake. Conclusions: An endomyocardial biopsy may be necessary for confirming the diagnosis of ATTR-CM in patients with clinical and imaging signs of cardiac amyloidosis but no cardiac radiotracer uptake in BS. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Materials and Methods Results Conclusions Trial Registration This study examined the prevalence of oral signs and symptoms in paraneoplastic syndromes.A systematic search on oral paraneoplastic syndromes was conducted in MEDLINE/PubMed, Ovid, and Scopus databases from inception to April 1, 2024. Risk of bias was evaluated using the MURAD or Quality in Prognosis Studies tools, and a random‐effects meta‐analysis was performed. Evidence quality was rated using the GRADE approach.The study sample comprised 811 participants from 487 studies. Oral manifestations predominantly affected patients with paraneoplastic pemphigus, mucous membrane pemphigoid, and acanthosis nigricans. Palate is the most frequently affected site (18.2%; 95% confidence interval [CI] 14.7–21.9), while erosion was the most common lesion type (83.3%; 95% CI 72.2–92.0) associated with the underlying malignancy. The prevalence of death in people with paraneoplastic syndromes was 50.9% (95% CI 39.9–61.7), while the prevalence of remission after neoplasm treatment was 63.4% (95% CI 49.9–76.0). GRADE assessment revealed uniformly low to very low certainty for all outcomes studied.Further research is needed to understand the mechanisms behind these oral manifestations, which is crucial for earlier paraneoplastic syndrome diagnosis and optimal patient management.PROSPERO number: CRD42022328921 [ABSTRACT FROM AUTHOR]

Background: Sickle cell hepatopathy (SCH) is a relatively uncommon complication of sickle cell disease (SCD), yet it does not accommodate variations in presentation, outcome, or severity according to age. Aim: To present SCH characteristics and assess the effect of implementation of a high-suspicion systematic diagnostic approach and early intervention plan of management. Methods: This case series presented the characteristics of five children with SCD with variable hepatic manifestation and implemented a diagnostic approach that included testing the transaminases and bilirubin in any patient with any suspicion of liver affection. Results: The five patients had a complicated SCD history. They all presented with fever, abdominal pain, and deepening of jaundice. The final diagnosis was reached with a more individualized approach; two had significant coagulopathy and were diagnosed with sickle cell intrahepatic cholestasis, while one had normal synthetic functions of the liver with rising transaminases and bilirubin levels, as well as high titer of Epstein–Barr virus diagnosed as acute viral hepatitis complicated with sickle cell hepatic crisis. One other patient had markedly elevated bilirubin with mild elevation of transaminases, and magnetic resonance cholangiopancreatography showed acute extrahepatic biliary dilatation treated by endoscopic removal of the stone. The fifth patient proved to have portal vein thrombosis by portal duplex causing portal hypertension and decompensated liver. The management plan included early exchange transfusion to keep their hemoglobin S (HbS) below 15% which was performed in three of the patients, in addition to aggressive supportive measures for correction of coagulopathy with full recovery and normalization of their liver functions. Conclusion: Despite the diagnostic challenges, the lack of standard diagnostic criteria, and the overlapping clinical presentation of SCH, the management and outcomes improved by following a systematic diagnostic approach. [ABSTRACT FROM AUTHOR]

Introduction: To mitigate gastroparesis as well as other post-operative complications, we undertook a prospective multicenter study to assess the feasibility, safety, and efficacy in the short-term outcomes of laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation. Methods: A prospective descriptive study on 37 patients with laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation from January 2019 to March 2023. The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated. Results: In our study, all patients were male, with dysphagia as the predominant symptom (45.9%). Esophageal cancer incidence was similar between middle and lower thirds. Nodules were the primary finding on esophagoscopy (48.6%). Preoperative pyloric dilation averaged 31.2 min without complications. Surgical duration ranged from 225 to 400 min (mean 305). Gastric tube fluid volume averaged 148.9 ± 110.66 ml per day. Among 34 post-operative cases underwent gastric transit scans, most had non-dilated stomachs with efficient pyloric drug circulation. Three cases required prolonged ventilation, precluding pyloric circulation scans. Four patients developed chylous fistula, one requiring chest tube embolization. Recurrent laryngeal nerve damage occurred in 10.8% of cases. Conclusion: After evaluating esophageal cancer patients undergoing laparoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation, it was found that this procedure is safe, effective, and significantly reduces postoperative gastroparesis and related complications. [ABSTRACT FROM AUTHOR]

Introduction: Hidradenitis suppurativa is a chronic, recurring skin condition characterized by inflammation of the terminal hair follicle. It presents as painful, deep-seated, inflamed lesions such as nodules, fistulas, and abscesses. While the mean onset age for hidradenitis suppurativa is typically between 21 and 29 years, the condition can also manifest in childhood. Aim: To review the clinical and demographic characteristics of pediatric-onset hidradenitis suppurativa patients. Material and methods: We present a case series of 42 patients with pediatric-onset hidradenitis suppurativa (onset age 0–18 years) and their management from two tertiary referral centres. Demographic, clinical, and laboratory data were assessed at the Department of Dermatology, National Medical Institute of the Ministry of the Interior and Administration, Warsaw, Poland, and the Department of Dermatology, Venereology, and Allergology, Medical University of Gdansk, Poland, from January 2000 to May 2023. This report details the epidemiology, clinical course, and management of the reported pediatric-onset hidradenitis suppurativa cases. Results: The median age of onset in our patients was 14 years (range: 5–17). The cohort comprised 20 (48%) males and 22 (52%) females. The most frequent lesion locations were in the inguinal folds and armpits, with additional occurrences in the buttocks and lower abdomen. Common comorbidities included obesity, hypothyroidism, and affective disorders. The treatment regimen for most patients involved topical clindamycin, systemic antibiotics, oral retinoids, and surgical excisions. Additionally, biologic treatments such as adalimumab, infliximab, and secukinumab were administered. Conclusions: This study affirms that the clinical course and treatment methods in patients with pediatric-onset hidradenitis suppurativa are similar to the adult-onset form. Improved disease awareness enables earlier diagnosis, preventing the deterioration of skin lesions, a decrease in quality of life, and the onset of comorbidities, especially affective disorders, which are prevalent among patients with hidradenitis suppurativa. [ABSTRACT FROM AUTHOR]

This study reports two cases of Global Rostral Midbrain Syndrome (GRMS) and corpus callosum infarction in the context of shunt overdrainage caused by obstructive hydrocephalus due to aqueductal stenosis. We detail how thorough clinical evaluation and appropriate investigation helped avoid a coma misdiagnosis and describe the excellent response to pharmacological treatment and successful neurorehabilitation in both cases. We analyze the cognitive profile of patients with GRMS, a rare condition that mimics disorders such as coma and progressive supranuclear palsy at various stages. In conscious cases, GRMS typically presents with parkinsonian syndrome, Parinaud syndrome, and cognitive issues. The awareness of this rare complication of shunt overdrainage facilitates more accurate diagnosis and better management. [ABSTRACT FROM AUTHOR]

Introduction: Spigelian hernias are among the rare primary ventral hernias. Diagnosis is often difficult, as many cases are asymptomatic. Spigelian and inguinal hernias are usually considered separately in current scientific literature. With this case series, we want to illustrate a possible relationship between the neighboring hernia types. Methods: In this article, we report on a case series of Spigelian hernias that were operated on in five hernia centers in the period from January 1st, 2021 to October 31st, 2023. We have summarized all patient characteristics with previous operations and the result of the secondary operation. Results: We report a case series with 24 Spigelian hernias, 15 of which have a connection to previous inguinal hernias. In these cases, however, it is not certain whether these are primarily overlooked or occult hernias or whether these Spigelian hernias have arisen secondarily, as a result of previous hernia surgery. Summary: With this case series, we would like to point out a possible connection between Spigelian hernia and inguinal hernia. Further studies are needed to shed more light on this entity and explain its genesis. [ABSTRACT FROM AUTHOR]

Further study is needed to determine the safest mode of delivery and anesthetic management for parturients with ventriculoperitoneal shunts (VP). Prior recommendation for delivery in women with ventriculoperitoneal shunts was cesarean delivery. However, both vaginal delivery and neuraxial anesthesia have been shown to be safe in women with appropriately functioning VP shunts. We present a case series of parturients with VP shunt. Parturients with VP shunts were identified and VP shunt placement indications, neurologic symptoms during pregnancy, delivery mode, anesthetic type, and postpartum complications were reviewed. Forty patients were identified, and fifteen women with twenty deliveries were included. Two women experienced neurological symptoms during pregnancy and one required postpartum shunt revision for blurry vision and ataxia. There were ten cesarean deliveries and ten vaginal deliveries (eight normal spontaneous, one vacuum assisted, and one forceps assisted). Assisted vaginal deliveries were performed to decrease Valsalva including the patient with neurological symptoms related to shunt malfunction. Of the vaginal deliveries, six (60%) had epidural analgesia. Anesthesia for cesarean delivery included neuraxial anesthesia (n = 5) and general anesthesia (n = 5). In our cohort, women with VP shunt received neuraxial blockade without complication. Neuraxial techniques should be offered to women with appropriately functioning VP shunt. [ABSTRACT FROM AUTHOR]

Background Carers play an important role in supporting patients diagnosed with high-grade glioma (HGG). However, this experience is frequently distressing and many carers require support. Objectives To describe unmet needs of highly distressed carers of people with HGG and recommendations and referrals made by a nurse to support them within the Care-IS trial. Methods Descriptive case series. Carers of people with HGG in the Care-IS trial reporting severe anxiety and/or depression at baseline and/or 4 months and high distress at baseline (during chemoradiotherapy) and at 4 months were included. Carers completed the Partner and Caregiver Supportive Care Needs Scale and Brain Tumor Specific Unmet Needs Survey for carers at baseline, 2, 4, 6, and 12 months. Monthly nurse telephone assessments documented carers' needs, recommendations, and referrals made. Data are reported descriptively. Results Four highly distressed carers were identified (N  = 98). Each reported a moderate-high need at ≥1 timepoint for: financial support and/or travel insurance; making life decisions in uncertainty; information about cancer prognosis/likely outcome; and coping with unexpected treatment outcomes. Specific brain tumor unmet needs were: adjusting to changes in personality, mental and thinking abilities, and accessing government assistance. Nurses provided information about treatment, side effects, and practical support. Recommendations for clinical care and referrals to community-based services, and medical specialists were offered. Conclusions Highly distressed carers have diverse support needs in many domains, which can change over time. Nurses were critical in identifying carers' needs, providing support, and making referrals. Carers' distress and needs require ongoing screening and management. [ABSTRACT FROM AUTHOR]

Background and purpose: Cerebral palsy (CP) is a congenital neurological disorder that causes musculoskeletal weakness and biomechanical dysfunctions. Strength training guidelines recommend at least 70% of 1-repetition maximum to increase muscle strength and mass. However, individuals with CP may not tolerate such high exercise intensity. Blood flow restriction (BFR) can induce similar gains in strength and muscle mass using loads as low as 20% to 30% 1-repetition maximum. This case series described the safety, feasibility, and acceptability of BFR in adults with CP and examined changes in muscle mass and strength. Case description: Three male participants with gross motor function classification system level 3 CP underwent strength training using a periodized 8-week BFR protocol. Outcomes included: Safety via blood pressure during and post-BFR exercises in addition to adverse event tracking; Feasibility via number of support people and time-duration of BFR exercises; Acceptability via rate of perceived discomfort (0-10) and qualitative interviews; Muscle Mass via ultrasonographic cross-sectional area of the quadriceps and hamstring; and Strength via (1) 3-repetition maximum in the leg press and knee extension, (2) isometric knee flexor and extensor muscle force measured with a hand-held dynamometer, and (3) 30-second sit-to-stand test. Intervention: Participants replaced 2 exercises from their current regimen with seated knee extension and leg press exercises using progressively higher limb occlusion pressure and exercise intensity. Limb occlusion pressure started at 60%, by week 4 progressed to 80%, and then remained constant. The exercise repetition scheme progressed from fixed nonfailure repetition sets to failure-based repetition sets. Outcomes: Blood pressure never exceeded safety threshold, and no adverse events were reported. The BFR training was time-consuming and resource-intensive, but well-tolerated by participants (rate of perceived discomfort with a mean value of 5.8, 100% protocol adherence). Strength, as measured by 3-repetition maximum testing and 30-second sit-to-stand test, increased, but isometric muscle force and muscle mass changes were inconsistent. Discussion: Blood flow restriction may be an effective means to increase strength in adults with CP who cannot tolerate high-intensity resistance training. Future research should compare BFR to traditional strength training and investigate mediators of strength changes in this population. Video abstract available: for more insights from the authors (see the Video, Supplemental Digital Content available at: http://links.lww.com/JNPT/A473 ). [ABSTRACT FROM AUTHOR]

Objectives: X‐linked hypophosphatemia (XLH) is a rare genetic disease that disturbs bone and teeth mineralization. It also affects craniofacial growth and patients with XLH often require orthodontic treatment. The aim of this study was to describe changes in the dental health of XLH children during orthodontic treatment compared with those in matched controls undergoing similar orthodontic procedures. Materials and Methods: For this retrospective case–control study, we included all individuals less than 16 years old diagnosed with XLH, orthodontically treated in our centre from 2016 to 2022 and pair‐matched them to patients with no chronic or genetic conditions. Clinical and radiological parameters concerning their malocclusion, craniofacial discrepancy and the characteristics and iatrogenic effects of their orthodontic treatment were analysed. Results: Fifteen XLH patients (mean age: 11.3 ± 2.1), pair‐matched to 15 control patients were included. Orthodontic treatment was successfully conducted in XLH patients with slightly shorter duration and similar iatrogenic effects as in the control group, except for the occurrence of dental abscess during and after orthodontic tooth movement. XLH patients did not show more relapse than the controls. Conclusion: Despite the presence of oral manifestations of XLH such as spontaneous abscesses, XLH patients can undergo orthodontic treatment with no obvious additional iatrogenic effects. [ABSTRACT FROM AUTHOR]

Background The reverse-wiring technique (RWT) using a hairpin-bend wire is useful for percutaneous coronary intervention of a bifurcation lesion with an extremely angulated side branch (SB); however, it is not necessarily effective in some anatomical situations. We report a novel SB wiring technique, the U-turn wiring technique (UWT), that is useful for wiring an extremely angled SB proximal to the ectasia. Case summary In the first case, the bare wire took a U-turn in the ectasia of the diagonal branch and crossed towards the angled left anterior descending artery, but a coronary dissection occurred in the diagonal branch due to the continuous wire-pushing force. Therefore, in the second case, we used a microcatheter with distal flexibility to prevent guidewire-induced vessel injury at the ectasia site and safely advanced the wire to the distal portion of the extremely angulated SB. Discussion The UWT takes advantage of the ectasia as a space to U-turn the guidewire. The UWT does not require a hairpin-bend guidewire or a dual-lumen catheter. The guidewire can be easily pushed forward through a reversed SB. After successful wire insertion, the guidewire can be easily advanced deep into the side branch. The UWT facilitates wire crossing to a reverse-angled branch utilizing the coronary ectasia anatomy through a simple manipulation. [ABSTRACT FROM AUTHOR]

Abstract Objective Temporal lobe encephaloceles (TLEN) have been implicated as a cause of temporal lobe epilepsy (TLE), the treatment which is primarily surgical; however, there is no clear consensus on the optimal surgical approach, because it is unclear whether TLE related to TLEN can be addressed by a restricted encephalocele resection or if a more extensive resection is required. The aim of the current article is to report the clinical and electrophysiological profile of patients with TLE secondary to TLEN who underwent stereotactic electroencephalography (SEEG) implantation to identify the epileptogenic network. Methods A retrospective review was performed of patients with TLE related to TLEN who underwent SEEG implantation. Medical charts were reviewed for demographic data, the results of noninvasive and invasive investigations, and operative details. Surgical outcomes were based on Engel classification with at least 6 months follow‐up. Results Nine patients were identified. The mean age at epilepsy onset was 28 years (range, 15–41 years), and 7/9 patients were female. Scalp EEG revealed interictal epileptiform activity most often maximum in the frontotemporal and/or temporal regions. A discrete TLEN was often not identified on initial imaging, but was identified during re‐review or at the time of surgery. Seizure onset zones during SEEG were localized to the mesial temporal structures, the temporal pole, or both. One patient became seizure‐free following SEEG and another refused further surgery. Of the 7 patients who underwent epilepsy surgery, 5/7 underwent an anterior temporal lobectomy—surgical outcomes were favorable, with 5/7 achieving Engel I outcomes. Significance Invasive SEEG monitoring demonstrated ictal onsets may not be restricted to the TLEN, and often the temporal pole and mesial structures are involved at seizure onset. Ictal propagation patterns vary significantly, which may be related to the underlying pathology and explain the variability in semiology. These findings may inform surgical treatment options. Plain language summary Temporal lobe encephaloceles can cause intractable epilepsy, although their presence may be missed on routine imaging. The management of encephaloceles is primarily surgical; however, the optimal surgical approach can be unclear. Invasive monitoring with SEEG may help characterize the epileptogenic network and result in more optimal surgical outcomes.

Lumbar ligamentous flavum hematoma (LFH) is a relatively rare pathology, and it is difficult to differentiate it from other cystic lesions. Full-endoscopic spine surgery (FESS), an excellent approach for clear and magnified operative visual field since it allows saline irrigation and minimizes destruction of surrounding tissues, has been applied to the treatment. This study aims to present a case series of patients with lumbar LFH treated by FESS. This case series consists of 17 lumbar LFH cases treated by FESS between May 2018 and November 2021 at a single institution. Patient background and operative data were collected from their medical records. The numerical rating scale (NRS), Oswestry Disability Index (ODI), and European Quality of Life-5 Dimensions (EQ-5D) were recorded preoperatively and postoperatively. Elderly men tend to suffer from lumbar LFH at the L4/5 vertebral level. Discontinuity with facet joint was confirmed under endoscopic visualization in all 17 cases. Blood clots were also observed in all cases under endoscope. The mean operative time was 68.6 min without complication. The patients were discharged at average 1.4 days after FESS with significant improvement of NRS score (P < 0.001). ODI and EQ-5D scores 2-year postoperatively statistically improved (P < 0.001), and there was no recurrence during followup period. The operative outcomes of lumbar LFH treated by FESS were satisfactory. FESS excels not only in the diagnosis but also in the treatment of lumbar LFH.

Abstract Background The case fatality rate of untreated dengue is 20%; it can be reduced to less than 1% with optimal management. The leading causes of death in dengue patients are shock, bleeding, and acute liver injury. We describe the clinical features of patients who died of dengue and discuss the therapeutic challenges and pitfalls of complicated dengue. Methods This retrospective study was done in the intensive care unit (MICU) of the National Hospital of Sri Lanka over 30 months between 2021 and 2023. All patients who died of serologically confirmed dengue were incorporated. Results Of the 1722 ICU admissions, 44 (2.6%) patients were treated for dengue—of them, 11 (25.0%) died. Two patients were excluded as their deaths were not directly linked to dengue. Six were females. The average age was 40.2 years. The leading causes of death included shock (n = 5), acute liver failure (n = 6), intracranial bleeding (n = 2), and pulmonary embolism (n = 1). Patient 1 had concomitant leakage and bleeding, which did not respond to fluids or blood products. He developed fluid overload and acute liver failure (ALF) and died of multiorgan dysfunction. Patients 2–5 were in shock for a prolonged period due to leakage ± bleeding. Patients 2–5 developed ALF and lactic acidosis followed by multiorgan dysfunction. Patient 8 developed acute hepatitis and ALF without preceding shock. The patient was treated with immunosuppressants for myasthenia gravis. Patients 6 and 7 experienced intracranial bleeding. Patient 9 died of pulmonary embolism after prolonged ventilation for dengue encephalitis. Conclusions Prolonged shock, fluid overload and acute liver failure were common causes of dengue related deaths, in our study. Fluid overload occurred when vigorous crystalloid resuscitation was continued in patients who were poorly responding. A prompt switch to colloids or blood could have prevented overload. Patients who were in shock for a prolonged period become unresponsive to fluid resuscitation. How to manage dengue in patients who take anti-inflammatory drugs, immunomodulators, or antiplatelets is not known. Balancing the bleeding risk of dengue in patients predisposed to bleeding or thrombosis is a challenge.

Abstract Background Percutaneous endoscopic lumbar discectomy (PELD) has demonstrated variable efficacy in alleviating low back pain (LBP) associated with lumbar disc herniation (LDH). Sinuvertebral nerve ablation (SNA), which targets the nociceptive pathway implicated in discogenic LBP pathogenesis, has emerged as a potential adjunctive therapy. The efficacy of endoscopic radiofrequency ablation in enhancing PELD for the treatment of LBP in patients with LDH remains unclear. Methods A retrospective cohort study was conducted on LDH patients with concomitant LBP treated at the Spinal Surgery Department, China-Japan Friendship Hospital, from June 2020 to June 2023. Participants were categorized into two groups: PELD combined with SNA (n = 51) and PELD alone (n = 46). Primary outcome measures included the Visual Analog Scale (VAS) for pain, the Japanese Orthopaedic Association (JOA) score, and the Oswestry Disability Index (ODI) at baseline and 1-, 3-, and 6-month follow-ups. Results Both groups exhibited significant improvements in VAS, JOA, and ODI scores for LBP and leg pain postoperatively compared to preoperative assessments. Notably, the PELD combined with SNA group demonstrated statistically significant superior outcomes in VAS, JOA, and ODI scores specifically for LBP compared to the PELD group. Conclusion The combination of PELD with SNA significantly improves LBP outcomes compared to PELD alone in LDH patients. While the observed improvements did not reach the minimal clinically important differences (MICD), these findings suggest that SNA may enhance the efficacy of PELD in LBP management.

Objective To evaluate the correction rate, accuracy of pedicle screw fixation and overall clinical efficacy of intravertebral osteotomy and internal fixation surgery with the assistance of 3D printing guide plates in treatment of severe kyphosis. Methods A single-center nonrandomized clinical pilot study was conducted on 19 patients (8 males and 11 females) with severe kyphosis undergoing intravertebral osteotomy between December 2018 and June 2023. Seven of them (CAD group) had preoperative planning with computer-aided design (CAD) and intraoperative guidance of individualized 3D printing guide plates. And another 12 patients (control group) were corrected with conventional pedicle screw placement. Postoperative evaluation included assessment of posterior Cobb angle, spinal angular correction rate, accuracy of pedicle screw placement and Oswestry Dysfunction Index (ODI) questionnaire. Results The 19 patients were at a mean age of 48.0 years, and followed up for 26.4 (9~54) months. All of them achieved relatively satisfactory corrective results, with those of the CAD group having a correction rate of 96.83% and those of the control group of 86.61%. There were no statistical differences in average intraoperative blood loss (857 vs 1 045 mL) and average operative time (344 vs 402 min), but significant difference was observed in average length of hospital stay (11 vs 18 d, P < 0.05) between the 2 groups. A total of 278 nails were placed in this study, including 70 guide-assisted pedicle screws, 97.1% of which were grade A or B. In the control group, 208 pedicle screws were placed, 93.8% of which were grade A or B. Postoperative CT/X-ray scanning displayed that both groups achieved certain correction for kyphosis. No obvious difference was found in the average spinal angular correction (43.37° vs 36.10°), and significantly higher correction rate was seen in the CAD group than the control group (96.83% vs 86.61%, P < 0.01). The ODI value was notably lower in the CAD group than the control group (P < 0.05). Conclusion CAD-assisted preoperative planning, surgical simulation and individualized 3D printing guide plates can promote surgical correction and accuracy of pedicle screw placement and improves the quality of life of patients with severe kyphotic deformity.