Artery of Percheron Infarction: Clinical Presentation and Outcomes.

Background and Objectives: Occlusion of the artery of Percheron (AOP) produces bilateral thalamic infarction classically leading to deficits of arousal. This nonspecific presentation complicates the diagnosis of acute ischemic stroke. We sought to describe the spectrum of clinical presentation, diagnostic neuroimaging findings, and outcomes in AOP infarction (AOPi). Methods: We conducted a keyword search of our health system's neuroimaging database from 2014 to 2022 to identify patients with AOPi. We abstracted patient demographics, clinical presentation, neuroimaging findings, acute treatment, and modified Rankin Scale (mRS) scores (at baseline, 3 months, and 12 months). We used descriptive statistics to report our findings. Results: Our initial keyword search identified 192 potential AOPi cases. Fifteen cases of AOPi were confirmed and included in our study (8 female [53%], median age 65 years [interquartile range (IQR): 59.5-79.5], median presenting NIHSS 6 [IQR: 2-22]). Common clinical findings on presentation were systolic blood pressure (SBP) > 140: 12 patients (80%); decreased level of consciousness (LOC): 11 patients (73%); diplopia: 8 patients (57%); disorientation: 6 patients (42%); dysarthria: 4 patients (28%); and acute memory/cognitive disturbance: 3 patients (21%). Twelve cases (80%) presented to the emergency department (ED). Median time from symptom onset to ED arrival was 774.5 minutes (IQR: 202.25-3789.0), 4 cases (27%) arrived within 4.5 hours, and one patient (7%) received intravenous thrombolysis. The median time from ED arrival to stroke diagnosis was 519.0 minutes (IQR: 227.5-1307). Head CT was only diagnostic when obtained >570 minutes from time last known well; MRI was diagnostic at all time points. Rates of functional independence (mRS ≤2) at baseline, 3 months, and 12 months were 64%, 21%, and 18%, respectively. Discussion: The diagnosis of stroke was considerably delayed in patients with AOPi, and only one patient received IV thrombolysis. SBP >140, impaired consciousness, and diplopia were the most common findings at presentation. CT was often nondiagnostic, but MRI demonstrated bilateral thalamic infarct in all cases. AOPi caused considerable long-term morbidity. Clinicians should maintain a high degree of suspicion for AOP stroke and consider thrombolysis in appropriately selected patients.

Does implant placement using a minimally invasive technique increase early failures among trainees at an academic center?

PURPOSE: This study aims to identify whether dental implants placed using a flapless technique have a higher early failure rate, defined as failure within 6 months of placement, compared to implants placed with flap elevation when a surgical guide is not used. METHODS: A retrospective cohort study was conducted to evaluate implants placed with either flapless (FL) or mucoperiosteal flap (MF) surgery between 2006 and 2012 at the Philadelphia VA Medical Center (PVAMC). Implant status after FL or MF surgery was assessed using dental encounter and radiographs at subsequent follow-up appointments to assess for early implant failures within 6 months of implant placement. RESULTS: The FL technique was used to place 89 implants in 38 subjects, while the MF technique was used to place 381 implants in 139 subjects. Early failure occurred in 37 implants, of which 13 occurred in the FL group and 24 occurred in the MF group. FL surgery was found to be associated with a 265% increase in early implant failure (OR 2.653; 95% CL 1.287-5.469) and was statistically significant (p = 0.0064). Residents were over 200% more likely to have an early implant failure when using the FL technique (OR 2.314; 95% CL 1.112-4.816), CONCLUSIONS: Analysis revealed flapless implant placement was associated with higher early implant failure rates. In addition, early failures were more likely to occur when residents placed an implant using the flapless technique. While FL surgery can result in long-term success, it is a more technique-sensitive approach that requires greater clinical skill and stricter case selection to perform.

Are proton pump inhibitors associated with implant failure and peri-implantitis?

OBJECTIVE: Proton pump inhibitors (PPIs) may be linked to implant failure by affecting bone metabolism and osseointegration. This study evaluated how PPIs influence long-term implant failure and peri-implantitis in PPI users and nonusers. STUDY DESIGN: This was a retrospective cohort study of patients treated at the Philadelphia Veterans Affairs Medical Center between 2006 and 2013. The primary predictor variable was PPI use. Outcome variables were long-term implant failure and the presence of peri-implantitis. Data gathered included demographic characteristics, medical comorbidities, implant location, and dimensions. Multivariate regression models measured independent factor associations. The final study cohort contained 933 implants placed in 284 patients. A total of 323 (32.6%) implants were placed in patients with ongoing PPI use. PPI users were less likely to smoke (22.1% vs 31.9%; P < .01) and use illicit drugs (5.0% vs 9.7%; P = .01) and more likely to have undergone prior bone grafting (18.3% vs 12.9%; P = .03). RESULTS: PPI use lost significance after controlling for confounding factors and was not an independent predictor of implant failure (odds ratio [OR], 0.801; 95% confidence interval [CI], 0.56-1.15; P = .24) or peri-implantitis (OR, 0.801; 95% CI, 0.56-1.15; P = .24). CONCLUSIONS: Our study found no independent associations between PPI use and implant failure or peri-implantitis. Contrary to published literature, PPIs may not influence implant health.

Does alcohol consumption protect against late dental implant failures?

PURPOSE: Social factors have been implicated in the development of peri-implant pathologies, including implant failure. This study aims to investigate whether alcohol consumption affects late dental implant failures. METHODS: A retrospective cohort study evaluated implants placed between 2006 and 2012 at the Philadelphia Veterans Affairs Medical Center. The primary predictor variable was alcohol consumption, measured as nonconsumption and mild, moderate, and heavy consumption. The primary outcome variable was late dental implant failure. Univariate, bivariate, and multivariate statistics were applied, with P < .05 used to define statistical significance. RESULTS: Our cohort consisted of 103 patients and 295 implants with a 5-year minimum follow-up. Most patients were male (93%) with an average age of 60 at the time of implant placement. Late implant failure was associated with 30 implants. Compared to nonconsumption, mild consumption was associated with a 75% decrease in late implant failure (P = .0494), moderate consumption was associated with a 60% decrease (P = .3826), and heavy consumption was associated with a 200% increase (P < .1782). Compared to mild consumption, heavy consumption was associated with an 847% increase in late failure (P = .0135). CONCLUSIONS: Results from this retrospective cohort analysis suggest that mild alcohol consumption is associated with a decrease in late dental implant failures.

Hygiene Recall in Diabetic and Nondiabetic Patients: A Periodic Prognostic Factor in the Protection Against Peri-Implantitis?

PURPOSE: Diabetes mellitus is associated with an increased risk of poor outcomes with dental implant placement. This study aims to identify if frequency of hygiene visits is a protective factor for the development of peri-implantitis in diabetic patients. METHODS: A retrospective cohort design was conducted on patients presenting for dental implant placement at the Philadelphia Veterans Affairs (VA) Medical Center from 2006 to 2012. The primary predictor variable was hygiene frequency, recorded as either infrequent, annual (7-12 month recall), or biannual (≤6-month recall). The number of months between implant placement and the presence of peri-implantitis was the primary outcome (time-to-peri-implantitis) variable, which was assessed on a subject level and adjusted for clustered, correlated multiple implants on the same subject. Additional variables were greater than or equal to 60 years of age, male gender, smokers, short implant length, diabetes, uncontrolled diabetes, and removable prostheses. Descriptive, univariate, and Cox proportional hazards regression statistics were computed to measure associations with peri-implantitis with P ≤ .05 used to define statistical significance. RESULTS: The study sample was composed of 286 patients. In total, 748 implants were placed. Subjects greater than or equal to 60 years of age were 2 times more likely to develop peri-implantitis (hazards ratio (HR) = 2.015, 95% Cl (0.985-4.119), P = .0549). Subjects receiving implant-supported removable prostheses were 2.3 times more likely to develop peri-implantitis (HR = 2.315, 95% CI (1.006-5.327), P = .0485). With each hygiene visit, patients' risk of developing peri-implantitis decreased 20% (HR = 0.805, 95% Cl (0.394-1.647), P = .5528). In addition, diabetic patients were 49% more likely to develop peri-implantitis (HR = 1.491, 95% CI (0.758-2.936), P = .2475) than nondiabetic patients. CONCLUSIONS: Diabetic patients may be at increased risk for the development of peri-implantitis and an increased frequency of hygiene visits may reduce peri-implant diseases.

Is Alcohol Consumption Associated With Protection Against Peri-Implantitis? A Retrospective Cohort Analysis.

PURPOSE: Recent studies have pointed to the effects of social factors on the health of dental implants. We investigated whether varying levels of alcohol consumption will influence the health of dental implants and associated peri-implant inflammation. PATIENTS AND METHODS: A retrospective cohort study was performed to evaluate implants placed from 2006 to 2012 at the Philadelphia Veteran's Affairs Medical Center. Alcohol consumption was gathered from the health maintenance records within 3 months of implant placement and served as the predictor variable. Analysis was performed at follow-up visits for the presence of the outcome variable, peri-implantitis, which was assessed at an implant level. A multivariable generalized estimating equation logistic regression model was constructed, and a Wald test was used to analyze the statistical significance of each parameter. The results were interpreted as an odds ratio estimate, including the 95% confidence interval. Descriptive statistics were used to compute and analyze the data, with P < .05 used to define statistical significance. RESULTS: Demographically, our cohort consisted mainly of male patients (92%), with an average age of 60 years at implant placement. The mean interval to peri-implantitis was 30 ± 25 months. Peri-implantitis occurred most frequently within 2 years of implant placement. The incidence of peri-implantitis was greatest among heavy alcohol consumers (42%) and lowest among mild and moderate consumers (12 and 6%, respectively). Compared with no consumption, mild alcohol consumption was associated with a 47% decrease in peri-implantitis (P < .0223) and moderate consumption was associated with a 75% decrease (P < .0250). Heavy consumption was associated with a nearly threefold increase in peri-implantitis (P < .0001). CONCLUSIONS: The results from our retrospective cohort analysis revealed that mild to moderate alcohol consumption is associated with a lower rate of peri-implantitis. However, heavy consumption was associated with an increase in the incidence of peri-implantitis among patients with dental implants.

Nontraumatic Vascular Emergencies of the Neck.

Nontraumatic vascular emergencies of the head and neck are uncommon, but can occur in patients with central venous catheters, head and neck infections, and in patients with head and neck cancer. Recognizing the imaging findings of vascular complications in these patient populations is critically important to ensure expeditious treatment to avoid significant morbidity and mortality.

Reducing Unnecessary Shoulder MRI Examinations Within a Capitated Health Care System: A Potential Role for Shoulder Ultrasound.

PURPOSE: MRI is frequently overused. The aim of this study was to analyze shoulder MRI ordering practices within a capitated health care system and explore the potential effects of shoulder ultrasound substitution. METHODS: We reviewed medical records of 237 consecutive shoulder MRI examinations performed in 2013 at a Department of Veterans Affairs tertiary care hospital. Using advanced imaging guidelines, we assessed ordering appropriateness of shoulder MRI and estimated the proportion of examinations for which musculoskeletal ultrasound could have been an acceptable substitute, had it been available. We then reviewed MRI findings and assessed if ultrasound with preceding radiograph would have been adequate for diagnosis, based on literature reports of shoulder ultrasound diagnostic performance. RESULTS: Of the 237 examinations reviewed, 106 (45%) were deemed to be inappropriately ordered, most commonly because of an absent preceding radiograph (n = 98; 92%). Nonorthopedic providers had a higher frequency of inappropriate ordering (44%) relative to orthopedic specialists (17%) (P = .016; odds ratio = 3.15, 95% confidence interval = 1.24-8.01). In the 237 examinations, ultrasound could have been the indicated advanced imaging modality for 157 (66%), and most of these (133/157; 85%) could have had all relevant pathologies characterized when combined with radiographs. Regardless of indicated modality, ultrasound could have characterized 80% of all cases ordered by nonorthopedic providers and 50% of cases ordered by orthopedic specialists (P = .007). CONCLUSIONS: Advanced shoulder imaging is often not ordered according to published appropriateness criteria. While nonorthopedic provider orders were more likely to be inappropriate, inappropriateness persisted among orthopedic providers. A combined ultrasound and radiograph evaluation strategy could accurately characterize shoulder pathologies for most cases.

Human leukocyte antigen genetics and clinical features of self-treated patients on a gluten-free diet.

BACKGROUND AND AIMS: Increasingly, people start a gluten-free diet (GFD) without a clear celiac disease (CD) diagnosis. Human leukocyte antigen (HLA) genotyping is useful in ruling out CD in patients with equivocal results of serologic testing or small-bowel biopsy (SBB), but its utility and the clinical features of patients on self-treated GFD (ST-GFD) are largely unknown. METHODS: Retrospective study of single tertiary care center cohort compared 137 patients on ST-GFD and 443 patients with well-defined CD. We compared HLA genotype, symptoms, serologic and SBB results, and response to GFD between the 2 groups. Analysis used univariate logistic regression modeling, adjusted for age and sex. RESULTS: Patients with ST-GFD presented more often with diarrhea (P<0.001), abdominal distention (P<0.001), flatulence (P=0.002), cramping (P=0.02), itchy skin (P=0.02), oral inflammation (P=0.04), and constipation (P=0.01) and less often with anemia (P<0.001) or malaise (P=0.02) than CD patients. In addition, 41% did not carry DQ2.5 and DQ8 versus 6% of CD patients (P<0.001). Only 2% of ST-GFD patients had SBB clearly consistent with CD. Family history of CD showed no difference between groups (P=0.77). Although CD patients had a statistically higher rate of GFD benefit, both groups had a high responsiveness rate (98% vs. 94%; P=0.03). CONCLUSIONS: HLA genotyping is useful in evaluating patients on an ST-GFD. Although confirmed CD is rare in self-treated patients, most still report benefit from GFD regardless of DQ2 and DQ8 status. Nonceliac gluten sensitivity may play a role.

Perspective on radiation risk in CT imaging.

Awareness of and communication about issues related to radiation dose are beneficial for patients, clinicians, and radiology departments. Initiating and facilitating discussions of the net benefit of CT by enlisting comparisons to more familiar activities, or by conveying that the anticipated radiation dose to an exam is similar to or much less than annual background levels help resolve the concerns of many patients and providers. While radiation risk estimates at the low doses associated with CT contain considerable uncertainty, we choose to err on the side of safety by assuming a small risk exists, even though the risk at these dose levels may be zero. Thus, radiologists should individualize CT scans according to patient size and diagnostic task to ensure that maximum benefit and minimum risk is achieved. However, because the magnitude of net benefit is driven by the potential benefit of a positive exam, radiation dose should not be reduced if doing so may compromise making an accurate diagnosis. The benefits and risks of CT are also highly individualized, and require consideration of many factors by patients, clinicians, and radiologists. Radiologists can assist clinicians and patients with understanding many of these factors, including test performance, potential patient benefit, and estimates of potential risk.

Glycemic control in non-critically ill hospitalized patients: a systematic review and meta-analysis.

BACKGROUND: The effect of intensive therapy to achieve tight glycemic control in patients hospitalized in non-critical care settings is unclear. METHODS: We conducted a systematic review and meta-analysis to determine the effect of intensive glycemic control strategies on the outcomes of death, stroke, myocardial infarction, incidence of infection, and hypoglycemia. We included randomized and observational studies. Bibliographic databases were searched through February 2010. Random effects model was used to pool results across studies. RESULTS: Nineteen studies (nine randomized and 10 observational studies) were included. The risk of bias across studies was moderate. Meta-analysis demonstrates that intensive glycemic control was not associated with significant effect on the risk of death, myocardial infarction, or stroke. There was a trend for increased risk of hypoglycemia (relative risk, 1.58; 95% confidence interval, 0.97-2.57), particularly in surgical studies and when the planned glycemic target was achieved. Intensive glycemic control was associated with decreased risk of infection (relative risk, 0.41; 95% confidence interval, 0.21-0.77) that was mainly derived from studies in surgical settings. CONCLUSION: Intensive control of hyperglycemia in patients hospitalized in non-critical care settings may reduce the risk of infection. The quality of evidence is low and mainly driven by studies in surgical settings.

IgG antibodies against bovine serum albumin in humans--their prevalence and response to exposure to bovine serum albumin.

Human exposure to bovine serum albumin (BSA) is very common and occurs through dietary and medicinal routes. Although great effort has been made to reduce exposure to BSA in pharmaceuticals to eliminate the threat of bovine spongiform encephalopathy, less attention has been given to assessing the human immune response after exposure to BSA. A sensitive quantitative radioimmunoassay was therefore developed to measure anti-BSA IgG antibodies in healthy subjects and in cancer patients participating in a randomized, placebo controlled clinical trial where they were exposed to BSA as an intrathoracic surgical sealant during pneumonectomy. Anti-BSA antibodies were detected in 55% of 60 healthy blood donors and 51% of 83 patients before lung cancer resection. The median antibody levels were the same in both cohorts; 0.086 microg/mL (range 0.016-19.5 microg/mL) for health blood donors and 0.062 microg/mL (range 0.009-44 microg/mL) for cancer patients. Six months after exposure of the cancer patients to BSA, the percentage of patients with anti-BSA antibody rose to 96% and the median antibody level rose to 19 microg/mL (range 0.009-258 microg/mL). Placebo-treated cancer patients showed no significant increase in the percentage of patients with anti-BSA antibody (41%) or the median antibody level (0.047 microg/mL; range 0.008-1.58) over 6 months. Western blot analysis confirmed the presence of anti-BSA antibody. Elevated levels of anti-BSA antibody were not associated with any detectable clinical events in either the healthy blood donors or the cancer patients.