Progressive microvascular failure in acute ischemic stroke: A systematic review, meta-analysis, and time-course analysis.

This systematic review, meta-analysis, and novel time course analysis examines microvascular failure in the treatment of acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT) and/or thrombolytic administration for stroke management. A systematic review and meta-analysis following PRIMSA-2020 guidelines was conducted along with a novel curve-of-best fit analysis to elucidate the time-course of microvascular failure. Scopus and PubMed were searched using relevant keywords to identify studies that examine recanalization and reperfusion assessment of AIS patients following large vessel occlusion. Meta-analysis was conducted using a random-effects model. Curve-of-best-fit analysis of microvascular failure rate was performed with a negative exponential model. Twenty-seven studies with 1151 patients were included. Fourteen studies evaluated patients within a standard stroke onset-to-treatment time window (≤6 hours after last known normal) and thirteen studies had an extended time window (>6 hours). Our analysis yields a 22% event rate of microvascular failure following successful recanalization (95% CI: 16-30%). A negative exponential curve modeled a microvascular failure rate asymptote of 28.5% for standard time window studies, with no convergence of the model for extended time window studies. Progressive microvascular failure is a phenomenon that is increasingly identified in clinical studies of AIS patients undergoing revascularization treatment.

Bacterial Meningitis With Cerebral Edema in a Young Adult: A Simulation Case for Medical Students.

Introduction: Simulation in the preclinical medical education setting is a beneficial tool for students to develop clinical skills, supplement preexisting knowledge, and prepare for clinical rotations and beyond. We detail the complete simulation scenario, including a participant postresponse questionnaire, of a 28-year-old male who developed bacterial meningitis after experiencing an upper respiratory infection in the days prior. Methods: Simulation fellows and faculty at the Alabama College of Osteopathic Medicine created a simulation scenario pertaining to bacterial meningitis. The scenario utilized a high-fidelity patient simulator, one standardized participant for patient voiceover, one standardized participant as a patient family member, and one standardized participant as a physician consultant on an as-needed basis. Sixteen preclinical medical students from various specialty interest groups were recruited to participate in the scenario and complete the postscenario questionnaire. Results: The simulation scenario was well received by the participants, and 15 of 16 completed the postscenario questionnaire. Ninety-three percent strongly agreed the simulation was a valuable clinical experience. Additionally, 73% of participants strongly agreed that the simulation experience was realistic, 80% strongly agreed that it tested their clinical reasoning ability, and 53% strongly agreed it was appropriate for their level of clinical knowledge. Discussion: Medical simulation is a valuable educational tool tailored to maximize student learning and supplement the traditional didactic curriculum. The successful development and implementation of our meningitis simulation case further supports the continued use of medical simulation in the preclinical setting.

Novel Technologies in Breast Imaging: A Scoping Review.

Breast cancer is one of the leading causes of death in the United States and can cause considerable suffering for not only the patient but their families as well. The current mainstay of screening is mammography, although this screening modality has its drawbacks. Multiple technologies have been recently explored in hopes of increasing breast cancer detection rates and decreasing false positive rates. Overall, improving breast cancer screening techniques has the potential to decrease cost, patient anxiety, and the use of unnecessary procedures. This review discusses multiple modalities including digital breast tomosynthesis, contrast-enhanced dual-energy digital mammography (CE DE DM), MRI with diffusion-weighted sequences and proton magnetic resonance spectroscopy. This paper was written with the objective of synthesizing information across several databases to provide clinicians with a more accessible tool to understand the underlying concepts behind these imaging modalities, as well as present reviewed data which highlights the benefits and drawbacks of these breast cancer-detecting techniques.

No-Reflow Post-Recanalization in Acute Ischemic Stroke: Mechanisms, Measurements, and Molecular Markers.

Acute ischemic stroke remains the primary cause of disability worldwide. For patients with large vessel occlusions, intravenous thrombolysis followed by mechanical thrombectomy remains the standard of care. Revascularization of the large vessel is typically successful. However, despite reopening of the occluded vessel, many patients fail to return to independence. Functional failure, despite macrovascular recanalization, is often referred to as the no-reflow phenomenon. Even with an extensive characterization of reperfusion in animal models, numerous mechanisms may explain no-reflow. Further, uniform measurements of this microvascular dysfunction and prognostic markers associated with no-reflow are lacking. In this review, we highlight a number of mechanisms that may explain no-reflow, characterize current multimodal measurements, and assess its molecular markers.

Implementation of Ultrasound in Preclinical Education at Osteopathic Medical Schools: A Scoping Review.

Ultrasound (US) is recognized as a practical and safe form of medical imaging that utilizes ultrasound waves to develop images for diagnostic and procedural purposes. The clinical use of US has dramatically increased over recent years, secondary to the ease of use, portability, and functionality of US. The success of point-of-care ultrasound implementation into residency curricula has further underscored the importance of US education and its potential for use earlier in medical instruction. Osteopathic medical education places a significant emphasis on anatomy, thus a scoping review of the literature regarding the use of US in osteopathic preclinical years is warranted. The goal of this scoping study is to assess the current literature regarding the implementation and benefit of US instruction in preclinical osteopathic medical curricula. Four resources were utilized for the review, including PubMed, Google Scholar, JOM (formerly JAOA), and AMED, each with contiguous criteria for applicable literature. The searches were performed before the end of January 2023. Inclusion criteria for researched literature focused on osteopathic preclinical utilization of US technologies. Articles were subsequently evaluated using thematic and contextual analysis. Of the 2,968 articles evaluated, 22 articles met the inclusion criteria. There were several themes associated with the implementation of US within osteopathic curricula, including positive student perceptions of the modality, improved learning outcomes, and adaptations of US instruction into anatomical sciences courses. There is a need for continued research regarding US implementation in preclinical osteopathic medical school education, including within anatomical sciences. A minority of osteopathic schools have published details regarding how US has been applied in their curriculum.

Glioblastoma Multiforme Survivor With Radiation-Induced Consequences: A Case Report.

Glioblastoma multiforme is an aggressive malignant tumor of the brain with a poor prognosis and no known cure. Current treatment options for this aggressive malignancy include surgical resection, adjuvant radiation therapy, and systemic pharmacological therapy. This case report presents one patient's experience with resolved glioblastoma multiforme treated by surgical resection and radiation therapy and discusses her later development and treatment of a radiation-induced meningioma. Despite developing radiation-induced morbidities, the patient experienced an extended life because of the aggressive treatment. It is thought that the young age of this patient at the time of diagnosis may have contributed to her prolonged survival time. When balancing aggressive treatment plans to increase survival time in glioblastoma multiforme patients, risks and potential consequences of treatment, such as post-surgical changes, vascular dementia, strokes, and meningiomas, should be weighed and discussed with the patient. Furthermore, striving for a high quality of life should be kept at the forefront of every treatment plan in all patients with glioblastoma multiforme.

Treatment and survival of supratentorial and posterior fossa ependymomas in adults.

Ependymoma is a rare primary brain or spinal cord tumor that arises from the ependyma, a tissue of the central nervous system. This study analyzed a large cohort of adult supratentorial and posterior fossa ependymoma tumors in order to elucidate factors associated with overall survival. We utilized the USA National Cancer Database to study adult World Health Organization grade II/III supratentorial and posterior fossa ependymoma patients treated between 1998 and 2011. Overall survival was estimated by the Kaplan-Meier method and factors associated with survival were determined using a multivariate Cox proportional hazards model. Among 1318 patients, 1055 (80.0%) had grade II and 263 (20.0%) anaplastic tumors located in the posterior fossa (64.3%) and supratentorial region (35.7%). Overall average age was 44.3years, 48.0% of patients were female, 86.5% were Caucasian, and 36.8% underwent near/gross total surgical resection. Radiotherapy was given to 662 patients (50.8%) and 75 (5.9%) received chemotherapy. Older age at diagnosis (hazard ratio [HR] 1.51, p<0.0001), high tumor grade (HR 1.82, p=0.005), and large tumor size (HR 1.66, p=0.008) were associated with poor survival. Females compared to males (HR 0.67, p=0.03) and patients with posterior fossa tumors versus supratentorial (HR 0.64, p=0.04) had a survival advantage. Our study showed that older patients, with supratentorial tumors, and high histological grade had an increased risk of mortality. A survival benefit was captured in females and patients with posterior fossa tumors. Adjuvant radiotherapy and chemotherapy did not confer a survival benefit among all patients, even after stratification by tumor grade or anatomical location.

Evolving role of endovascular treatment for MCA bifurcation aneurysms: case series of 184 aneurysms and review of the literature.

OBJECTIVE: This study evaluates the role of endovascular therapy for middle cerebral artery (MCA) aneurysms and its evolution over time. We are reporting a large case series of 184 MCA aneurysms and comparative analysis of the literature. METHODS: This was a retrospective review of a prospectively maintained database including all patients with MCA bifurcation aneurysms embolized between 2000 and 2013. There were 184 aneurysms in 166 patients, with 71 ruptured and 113 nonruptured aneurysms. RESULTS: Stent assistance was required in 70 cases (38·0%) and 3 cases (1·6%) required 'Y' stenting. The initial rate of total aneurysm occlusion was 59·8% and at delayed follow up was 90·1%. Seven embolizations resulted in thrombo-embolic complications (3·8%), with no cases of aneurysm re-bleeding, wire perforations, or other hemorrhages. Three patients with ruptured aneurysms died of causes unrelated to the embolization, and none with nonruptured aneurysms died in the follow-up period (total mortality 1·6% at 30 days post-procedure). A total of seven aneurysms (3·9%) required retreatment with an average follow up of 41 months. Prior to dedicated aneurysm stents, 68·8% of patients underwent embolization with the remainder surgically treated. Following the introduction of aneurysm stents in 2002, 92·0% of MCA aneurysms treated were embolized. CONCLUSIONS: During the past decade we have seen a treatment paradigm shift in MCA aneurysm treatment from surgical treatment to endovascular treatment. Developments in 3D angiography, more compliant balloons, dedicated aneurysm stents, complex coils, and antiplatelet therapy regimes have led to this transition for safe and effective management of these patients.

Sex, lies, and statistics: inferences from the child sexual abuse accommodation syndrome.

Victims of child sexual abuse often recant their complaints or do not report incidents, making prosecution of offenders difficult. The child with sexual abuse accommodation syndrome (CSAAS) has been used to explain this phenomenon by identifying common behavioral responses. Unlike PTSD but like rape trauma syndrome, CSAAS is not an official diagnostic term and should not be used as evidence of a defendant's guilt or to imply probative value in prosecutions. Courts have grappled with the ideal use of CSAAS in the evaluation of child witness testimony. Expert testimony should be helpful to the jurors without prejudicing them. The New Jersey Supreme Court ruled recently that statistical evidence about CSAAS implying the probability that a child is truthful runs the risk of confusing jury members and biasing them against the defendant. We review the parameters of expert testimony and its admissibility in this area, concluding that statistics about CSAAS should not be used to draw inferences about the victim's credibility or the defendant's guilt.

Data feedback and clinical process improvement in acute myocardial infarction.

BACKGROUND: Numerous reports have shown substantial undertreatment of acute myocardial infarction (AMI). The goal of this intervention study was to improve both the acute and discharge care of patients with AMI. Thirty-eight Tenet hospitals participated in a cardiac improvement collaborative called the Partnership for Change. Interventions included the implementation of a computerized concurrent data feedback system and the organization, staffing, and deployment of performance improvement teams at each hospital. METHODS: Data were collected on 11 394 patients with AMI between January 1, 2001, and June 30, 2002. We calculated rates of treatments including aspirin (first 24 hours and at discharge), beta-blocking agent (first 24 hours and at discharge), reperfusion using thrombolysis (first 30 minutes) or percutaneous intervention (first 2 hours), angiotensin-converting enzyme inhibitor (at discharge), smoking cessation counseling (during hospital stay), and referral to a cardiac rehabilitation program (at discharge). RESULTS: Statistically significant increases were seen for all indicators. Aspirin use during the first 24 hours increased from 86.4% to 96.5% and use at discharge increased from 70.0% to 87.4%. The use of beta-blocking agents during the first 24 hours increased from 51.4% to 88.4% and use at discharge increased from 62.4% to 83.5%. Reperfusion during the first 2 hours increased from 25.9% to 35.3%. Discharge use of angiotensin-converting enzyme inhibitors increased from 29.3% to 43.3%. Smoking cessation counseling increased from 35.1% to 80.6%. Referral to a cardiac rehabilitation program increased from 16.9% to 41.7%. All P values were <.001. CONCLUSIONS: The implementation of a rapid-cycle computerized concurrent data feedback system along with on-site process improvement teams was associated with a substantial increase in the use of both acute and discharge treatments for AMI.