Lumbar Erector Spinae Plane Block for Dega Pelvic Osteotomy in a Pediatric Patient With Complex Neurological Issues: A Case Report.

The erector spinae plane (ESP) block, initially designed for thoracic analgesia, has evolved into a versatile regional anesthesia technique with literature support for success in numerous contexts. In this case report, we highlight the successful application of ESP to provide postoperative analgesia for pediatric Dega osteotomy involving both the femoral head and acetabulum, in a patient with numerous neurological comorbidities that would have weighed against some more traditional regional anesthesia techniques. This case further highlights the versatility of ESP, demonstrating its use in blocking lumbar nerve roots in a pediatric patient with complex neurological challenges.

High prevalence of pre-treatment and acquired HIV-1 drug resistance mutations among non-citizens living with HIV in Botswana.

Background: Approximately 30,000 non-citizens are living with HIV in Botswana, all of whom as of 2020 are eligible to receive free antiretroviral treatment (ART) within the country. We assessed the prevalence of HIV-1 mutational profiles [pre-treatment drug resistance (PDR) and acquired drug resistance (ADR)] among treatment-experienced (TE) and treatment-naïve (TN) non-citizens living with HIV in Botswana. Methods: A total of 152 non-citizens living with HIV were enrolled from a migrant HIV clinic at Independence Surgery, a private practice in Botswana from 2019-2021. Viral RNA isolated from plasma samples were genotyped for HIV drug resistance (HIVDR) using Sanger sequencing. Major known HIV drug resistance mutations (DRMs) in the pol region were determined using the Stanford HIV Drug Resistance Database. The proportions of HIV DRMs amongst TE and TN non-citizens were estimated with 95% confidence intervals (95% CI) and compared between the two groups. Results: A total of 60/152 (39.5%) participants had a detectable viral load (VL) >40 copies/mL and these were included in the subsequent analyses. The median age at enrollment was 43 years (Q1, Q3: 38-48). Among individuals with VL > 40 copies/mL, 60% (36/60) were treatment-experienced with 53% (19/36) of them on Atripla. Genotyping had a 62% (37/60) success rate - 24 were TE, and 13 were TN. A total of 29 participants (78.4, 95% CI: 0.12-0.35) had major HIV DRMs, including at least one non-nucleoside reverse transcriptase inhibitor (NNRTI) associated DRM. In TE individuals, ADR to any antiretroviral drug was 83.3% (20/24), while for PDR was 69.2% (9/13). The most frequent DRMs were nucleoside reverse transcriptase inhibitors (NRTIs) M184V (62.1%, 18/29), NNRTIs V106M (41.4%, 12/29), and K103N (34.4%, 10/29). No integrase strand transfer inhibitor-associated DRMs were reported. Conclusion: We report high rates of PDR and ADR in ART-experienced and ART-naïve non-citizens, respectively, in Botswana. Given the uncertainty of time of HIV acquisition and treatment adherence levels in this population, routine HIV-1C VL monitoring coupled with HIVDR genotyping is crucial for long-term ART success.

Antimicrobial efficacy of a citric acid/hydrochloric acid blend, peroxyacetic acid, and sulfuric acid against Salmonella and background microbiota on chicken hearts and livers.

This study aimed at evaluating the efficacy of a blend of citric acid and hydrochloric acid (CP), peroxyacetic acid (PAA), and sulfuric acid (SA) against Salmonella and mesophilic aerobic plate counts (APC) on chicken hearts and livers. Samples were inoculated with a five-serovar cocktail of Salmonella at ca. 4.8 log CFU/g and treated by immersion with a water control (90 s), CP (5% v/v, 30 s), PAA (0.05% v/v or 500 ppm, 90 s), or SA (2% v/v, 30 s), all at 4°C and with mechanical agitation. Samples were vacuum packed and stored for up to 3 days at 4°C. Three independent replications were performed for each product, treatment, and time combination. The average Salmonella reductions in chicken hearts after 3 days were 1.33 ± 0.25, 1.40 ± 0.04, and 1.32 ± 0.12 log CFU/g for PAA, SA, and CP, respectively. For chicken livers, the values were 1.10 ± 0.12, 1.09 ± 0.19, and 0.96 ± 0.27 for PAA, SA, and CP, respectively. All antimicrobials reduced Salmonella counts in both chicken hearts and livers by more than one log, in contrast to the water control. All treatments effectively minimized the growth of APC for up to 3 days of refrigerated storage, and no differences in objective color values (L, a, or b) were observed. The poultry industry may use these antimicrobials as components of a multifaceted approach to mitigate Salmonella in nonconventional chicken parts.

Lack of IT and digital marketing professionals in hospitality: is it education's fault?

Information technology (IT) and digital marketing are perceived as the driving forces for promoting the development of the hospitality industry in a competitive market. However, there is a global shortage of workers to fill related positions, which hinders the sustainable growth of this industry. Thus, a qualitative thematic approach was adopted in this study to analyze textual data from experts to explore the reasons behind this shortage. Through careful design and analysis, three parties were identified as key generators, including education, industry, and staff/students. Meanwhile, the specific causes made by each party were presented to provide a detailed analysis of the issue. The findings are aimed to help solve the education and human resource issues in the hospitality industry. Nevertheless, the findings could have been more detailed if a follow-up interview was conducted after the thematic analysis.

Cerebral Digital Subtraction Angiography in Acute Intracranial Hemorrhage: Considerations in Critically Ill Children.

Cerebrovascular disorders are an important cause of morbidity and mortality in children. Although minimally invasive, cerebral digital subtraction angiography (DSA) has been shown to be safe in children and is a valuable, and perhaps underutilized, technique for the diagnosis and management of pediatric cerebrovascular disorders in the critical care setting. Through a case-based approach, we explore the utility of DSA in critically ill children with acute intracranial hemorrhage (ICH). We discuss the use of DSA in the acute management of aneurysm and arteriovenous malformation rupture as well as cerebral vasospasm. Those caring for critically ill children with acute ICH should consider cerebral DSA as part of a comprehensive approach to the diagnosis and management of these conditions.

Realtime online courses mutated amid the COVID-19 pandemic: Empirical study in hospitality program.

Real-time online courses (RTOCs), a new online learning mode, have been developed because of a longitudinal suspension of classes amid the COVID-19 pandemic worldwide. We explore an information model to review the learning process and outcomes of RTOCs, which conducted educational activities via social media. Results show that social media can be a potent mediation factor with the moderation of structural differentiation to facilitate online learning outcomes. Conclusions imply that the life-changing impact of COVID-19 has caused an evolutionary online education mode that can be hybridized with face-to-face education and massive open online courses to flourish education approaches and pedagogies.

First Description of the Composition and the Functional Capabilities of the Skin Microbial Community Accompanying Severe Scabies Infestation in Humans.

Epidemiological studies link Sarcoptes scabiei infection and impetigo. Scabies mites can promote Streptococcus pyogenes (Group A Streptococcus) and Staphylococcus aureus infections by breaching the skin barrier and excreting molecules that inhibit host innate immune responses. However, little is known about the composition and the function of the scabies-associated microbiota. Here, high-throughput whole-metagenome sequencing was used to explore the scabies-associated microbiome. Scabies mites including their immediate microenvironments were isolated from two patients with severe scabies in Northern Australia. Two ~45-50 million paired-end reads Illumina libraries were generated of which ~2 (5.1%) and 0.7 million (1.3%) microbial reads were filtered out by mapping to human (hg19) and mite draft genomes. Taxonomic profiling revealed a microbial community dominated by the phylum Firmicutes (A: 79% and B: 59%) and genera that comprise Streptococcus, Staphylococcus, Acinetobacter, and Corynebacterium. Assembly of the metagenome reads resulted in genome bins representing reference genomes of Acinetobacter baumannii, Streptococcus dysgalactiae (Group C/G), Proteus mirablis and Staphylococcus aureus. The contigs contained genes relevant to pathogenicity and antibiotics resistance. Confocal microscopy of a patient skin sample confirmed A. baumannii, Streptococci and S. aureus in scabies mite gut and faeces and the surrounding skin. The study provides fundamental evidence for the association of opportunistic pathogens with scabies infection.

Vestibular Implant Imaging.

Analogous to hearing restoration via cochlear implants, vestibular function could be restored via vestibular implants that electrically stimulate vestibular nerve branches to encode head motion. This study presents the technical feasibility and first imaging results of CT for vestibular implants in 8 participants of the first-in-human Multichannel Vestibular Implant Early Feasibility Study. Imaging characteristics of 8 participants (3 men, 5 women; median age, 59.5 years; range, 51-66 years) implanted with a Multichannel Vestibular Implant System who underwent a postimplantation multislice CT (n = 2) or flat panel CT (n = 6) are reported. The device comprises 9 platinum electrodes inserted into the ampullae of the 3 semicircular canals and 1 reference electrode inserted in the common crus. Electrode insertion site, positions, length and angle of insertion, and number of artifacts were assessed. Individual electrode contacts were barely discernible in the 2 participants imaged using multislice CT. Electrode and osseous structures were detectable but blurred so that only 12 of the 18 stimulating electrode contacts could be individually identified. Flat panel CT could identify all 10 electrode contacts in all 6 participants. The median reference electrode insertion depth angle was 9° (range, -57.5° to 45°), and the median reference electrode insertion length was 42 mm (range, -21-66 mm). Flat panel CT of vestibular implants produces higher-resolution images with fewer artifacts than multidetector row CT, allowing visualization of individual electrode contacts and quantification of their locations relative to vestibular semicircular canals and ampullae. As multichannel vestibular implant imaging improves, so will our understanding of the relationship between electrode placement and vestibular performance.

High-throughput metagenome analysis of the Sarcoptes scabiei internal microbiota and in-situ identification of intestinal Streptomyces sp.

Multiple parasitic arthropods of medical importance depend on symbiotic bacteria. While the link between scabies and secondary bacterial infections causing post infective complications of Group A streptococcal and staphylococcal pyoderma is increasingly recognized, very little is known about the microbiota of Sarcoptes scabiei. Here we analyze adult female mite and egg metagenome datasets. The majority of adult mite bacterial reads matched with Enterobacteriaceae (phylum Proteobacteria), followed by Corynebacteriaceae (phylum Actinobacteria). Klebsiella was the most dominant genus (78%) and Corynebacterium constituted 9% of the assigned sequences. Scabies mite eggs had a more diverse microbial composition with sequences from Proteobacteria being the most dominant (75%), while Actinobacteria, Bacteroidetes and Firmicutes accounted for 23% of the egg microbiome sequences. DNA sequences of a potential endosymbiont, namely Streptomyces, were identified in the metagenome sequence data of both life stages. The presence of Streptomyces was confirmed by conventional PCR. Digital droplet PCR indicated higher Streptomyces numbers in adult mites compared to eggs. Streptomyces were localized histologically in the scabies mite gut and faecal pellets by Fluorescent In Situ Hybridization (FISH). Streptomyces may have essential symbiotic roles in the scabies parasite intestinal system requiring further investigation.

Implementing pharmacogenetic testing in rural primary care practices: a pilot feasibility study.

Aim: Assess feasibility and perspectives of pharmacogenetic testing/PGx in rural, primary care physician (PCP) practices when PCPs are trained to interpret/apply results and testing costs are covered. Methods: Participants included PCPs who agreed to training, surveys and interviews and eligible patients who agreed to surveys and testing. 51 patients from three practices participated. Results: Prestudy, no PCP had ever ordered a PGx test. Test results demonstrated gene variations in 30% of patients, related to current medications, with PCPs reporting changes to drug management. Poststudy, test cost was still a concern, but now PCPs reported practical barriers, including the utilization of PGx results over time. PCPs and patients had favorable responses to testing. Summary: PGx testing is feasible in rural PCP practices.

Efficacy of Heat Mitigation Strategies on Core Temperature and Endurance Exercise: A Meta-Analysis.

Background: A majority of high profile international sporting events, including the coming 2020 Tokyo Olympics, are held in warm and humid conditions. When exercising in the heat, the rapid rise of body core temperature (T c ) often results in an impairment of exercise capacity and performance. As such, heat mitigation strategies such as aerobic fitness (AF), heat acclimation/acclimatization (HA), pre-exercise cooling (PC) and fluid ingestion (FI) can be introduced to counteract the debilitating effects of heat strain. We performed a meta-analysis to evaluate the effectiveness of these mitigation strategies using magnitude-based inferences. Methods: A computer-based literature search was performed up to 24 July 2018 using the electronic databases: PubMed, SPORTDiscus and Google Scholar. After applying a set of inclusion and exclusion criteria, a total of 118 studies were selected for evaluation. Each study was assessed according to the intervention's ability to lower T c before exercise, attenuate the rise of T c during exercise, extend T c at the end of exercise and improve endurance. Weighted averages of Hedges' g were calculated for each strategy. Results: PC (g = 1.01) was most effective in lowering T c before exercise, followed by HA (g = 0.72), AF (g = 0.65), and FI (g = 0.11). FI (g = 0.70) was most effective in attenuating the rate of rise of T c , followed by HA (g = 0.35), AF (g = -0.03) and PC (g = -0.46). In extending T c at the end of exercise, AF (g = 1.11) was most influential, followed by HA (g = -0.28), PC (g = -0.29) and FI (g = -0.50). In combination, AF (g = 0.45) was most effective at favorably altering Tc, followed by HA (g = 0.42), PC (g = 0.11) and FI (g = 0.09). AF (1.01) was also found to be most effective in improving endurance, followed by HA (0.19), FI (-0.16) and PC (-0.20). Conclusion: AF was found to be the most effective in terms of a strategy's ability to favorably alter T c , followed by HA, PC and lastly, FI. Interestingly, a similar ranking was observed in improving endurance, with AF being the most effective, followed by HA, FI, and PC. Knowledge gained from this meta-analysis will be useful in allowing athletes, coaches and sport scientists to make informed decisions when employing heat mitigation strategies during competitions in hot environments.

Molecular detection of tick-borne pathogens in canine population and Rhipicephalus sanguineus (sensu lato) ticks from southern Metro Manila and Laguna, Philippines.

BACKGROUND: The tropical climate of the Philippines and the high population of dogs, particularly in cities, favors the life-cycle of the brown dog tick, Rhipicephalus sanguineus (sensu lato), a vector of several canine tick-borne pathogens (TBPs) including zoonotic Rickettsia spp. Suspected cases of infections are commonly encountered in veterinary clinics, but the specific TBPs are rarely identified. Furthermore, infection with Rickettsia is not being clinically examined in dogs. In this study, the occurrence of TBPs in blood and ticks collected from household and impounded dogs in highly populated areas of the Philippines, Metro Manila, and the nearby province of Laguna, was examined. RESULTS: A total of 248 blood samples and 157 tick samples were subjected to PCR. First, samples were screened using primers for Anaplasma/Ehrlichia spp. and Babesia/Hepatozoon spp. Those that turned positive were further subjected to species-specific PCR. Rickettsia spp. were also detected through a nested PCR. Of the 248 blood samples, 56 (22.6%) were positive for Anaplasma/Ehrlichia spp., while 19 (7.6%) were positive for Babesia/Hepatozoon spp. Species-specific PCR revealed that 61 (23.4%) had a single TBP, with Ehrlichia canis being detected in 39 (15.7%) dogs, while 14 (5.6%) dogs were positive for different combinations of two to four TBPs. Rickettsia infection was detected in 6 (2.4%) dogs. In tick samples, 8 (3.2%) were positive for Ehrlichia/Anaplasma spp., while only 1 (0.63%) was positive for Babesia/Hepatozoon spp. As in the blood samples, E. canis was the most detected, being found in 5 (2%) samples. No tick samples tested positive for Rickettsia spp. CONCLUSION: Ehrlichia canis is the most common TBP affecting dogs in the Philippines. Co-infection with TBPs is quite common, hence testing for multiple TBPs is necessary. Through nested PCR, Rickettsia infection was detected in dogs, and to the authors' knowledge, this study provides the first molecular evidence of Rickettsia infection in dogs in the Philippines.

Endometrial carcinoma recurrence according to race and ethnicity: An NRG Oncology/Gynecologic Oncology Group 210 Study.

Non-Hispanic black (NHB) women are more likely to experience an endometrial carcinoma (EC) recurrence compared to non-Hispanic white (NHW) women. The extent to which tumor characteristics, socioeconomic status (SES) and treatment contribute to this observation is not well defined. In the NRG Oncology/Gynecology Oncology Group (GOG) 210 Study we evaluated associations between race/ethnicity and EC recurrence according to tumor characteristics with adjustment for potential confounders. Our analysis included 3,199 NHW, 532 NHB and 232 Hispanic women with EC. Recurrence was documented during follow-up. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between race/ethnicity and EC recurrence in models stratified by histologic subtype (low-grade endometrioid, high-grade endometrioid, serous, mixed cell, carcinosarcoma, clear cell) or stage (I, II, III) and adjusted for age, SES, body mass index, smoking status and treatment. In histologic subtype-stratified models, higher EC recurrence was noted in NHB women with low-grade endometrioid (HR = 1.94, 95% CI = 1.21-3.10) or carcinosarcomas (HR = 1.66, 95% CI = 0.99-2.79) compared to NHWs. In stage-stratified models, higher EC recurrence was noted among NHB women with stage I (HR = 1.48, 95% CI = 1.06-2.05) and Hispanic women with stage III disease (HR = 1.81, 95% CI = 1.11-2.95). Our observations of higher EC recurrence risk among NHB and Hispanic women, as compared to NHW women, were not explained by tumor characteristics, SES, treatment or other confounders. Other factors, such as racial differences in tumor biology or other patient factors, should be explored as contributors to racial disparities in EC recurrence.

I am not just a number

@#In this day and age of research and constantly improving methods of research conduct and protocols, policies are determined, to a large part, by the results of these researches, most of which are numbers. So in addressing the growing need to prevent blindness from Retinopathy of Prematurity (ROP), experts worldwide, in at least 2 major landmark studies and 4 World ROP Congresses, agreed on the definitions of high-risk criteria, with emphasis on timely referral. These were all meant to guide the pediatricians in referring premature babies for ROP screening. These efforts were meant to drive home a very important point: the occurrence of visually-debilitating stages of ROP are preventable. The incidence of blindness from ROP is quite small, but nonetheless, catastrophic to the patient. To speak of those numbers is not my purpose today. My purposes are to put a face and a voice to those who are “the tiny number … the small incidence” crying out from the outer edges of bar graphs, and to remind everyone that that tiny number of blind and nearly blind children are people with lives to live, and futures to look forward to, just like the rest of us. Certainly, opening that golden window of opportunity is the most important thing that one can do for the premature baby at risk of developing ROP. One is not born with ROP. No one wants to have it. No parent will want his child to have it. And if one does have it, one must be protected from the deleterious consequences of ROP. This will happen only if everyone concerned will just do what they have to do. Screening of a high-risk baby by an ophthalmologist cannot be done without a referral from the attending pediatrician. The tireless efforts of neonatologists and pediatricians in keeping the premature babies alive and managing all their life-threatening conditions are truly laudable. However, we must insist that sight is just as important. We must insist that high-risk babies be referred to an ophthalmologist for ROP screening. The importance of a wholistic approach in the management of a premature baby cannot be overemphasized. Quality of life should be a primary consideration when it comes to any situation where something has been compromised. To drive home a point, please do this: Imagine your child blind. Then think of everything that a blind child will miss in his life. Think of all the difficulties that the blind child will encounter in his entire life. Think of all the difficulties and the heartaches for the parents of the blind child. Then think of how this blind person will be when the doting parents who took care of him will one day no longer be around. A parent of an ROP blind child once said “To a parent there are no statistics. My child is always 100%.” And finally, think about these wise words from Nelson Mandela: History will judge us by the difference we make in the everyday lives of children.

Complement inhibition by Sarcoptes scabiei protects Streptococcus pyogenes - An in vitro study to unravel the molecular mechanisms behind the poorly understood predilection of S. pyogenes to infect mite-induced skin lesions.

BACKGROUND: On a global scale scabies is one of the most common dermatological conditions, imposing a considerable economic burden on individuals, communities and health systems. There is substantial epidemiological evidence that in tropical regions scabies is often causing pyoderma and subsequently serious illness due to invasion by opportunistic bacteria. The health burden due to complicated scabies causing cellulitis, bacteraemia and sepsis, heart and kidney diseases in resource-poor communities is extreme. Co-infections of group A streptococcus (GAS) and scabies mites is a common phenomenon in the tropics. Both pathogens produce multiple complement inhibitors to overcome the host innate defence. We investigated the relative role of classical (CP), lectin (LP) and alternative pathways (AP) towards a pyodermic GAS isolate 88/30 in the presence of a scabies mite complement inhibitor, SMSB4. METHODOLOGY/PRINCIPAL FINDINGS: Opsonophagocytosis assays in fresh blood showed baseline immunity towards GAS. The role of innate immunity was investigated by deposition of the first complement components of each pathway, specifically C1q, FB and MBL from normal human serum on GAS. C1q deposition was the highest followed by FB deposition while MBL deposition was undetectable, suggesting that CP and AP may be mainly activated by GAS. We confirmed this result using sera depleted of either C1q or FB, and serum deficient in MBL. Recombinant SMSB4 was produced and purified from Pichia pastoris. SMSB4 reduced the baseline immunity against GAS by decreasing the formation of CP- and AP-C3 convertases, subsequently affecting opsonisation and the release of anaphylatoxin. CONCLUSIONS/SIGNIFICANCE: Our results indicate that the complement-inhibitory function of SMSB4 promotes the survival of GAS in vitro and inferably in the microenvironment of the mite-infested skin. Understanding the tripartite interactions between host, parasite and microbial pathogens at a molecular level may serve as a basis to develop improved intervention strategies targeting scabies and associated bacterial infections.

Evaluation of Various Cooling Systems After Exercise-Induced Hyperthermia.

CONTEXT: Rapid diagnosis and expeditious cooling of individuals with exertional heat stroke is paramount for survival. OBJECTIVE: To evaluate the efficacy of various cooling systems after exercise-induced hyperthermia. DESIGN: Crossover study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-two men (age = 24 ± 2 years, height = 1.76 ± 0.07 m, mass = 70.7 ± 9.5 kg) participated. INTERVENTION(S): Each participant completed a treadmill walk until body core temperature reached 39.50°C. The treadmill walk was performed at 5.3 km/h on an 8.5% incline for 50 minutes and then at 5.0 km/h until the end of exercise. Each participant experienced 4 cooling phases in a randomized, repeated-crossover design: (1) no cooling (CON), (2) body-cooling unit (BCU), (3) EMCOOLS Flex.Pad (EC), and (4) ThermoSuit (TS). Cooling continued for 30 minutes or until body core temperature reached 38.00°C, whichever occurred earlier. MAIN OUTCOME MEASURE(S): Body core temperature (obtained via an ingestible telemetric temperature sensor) and heart rate were measured continuously during the exercise and cooling phases. Rating of perceived exertion was monitored every 5 minutes during the exercise phase and thermal sensation every minute during the cooling phase. RESULTS: The absolute cooling rate was greatest with TS (0.16°C/min ± 0.06°C/min) followed by EC (0.12°C/min ± 0.04°C/min), BCU (0.09°C/min ± 0.06°C/min), and CON (0.06°C/min ± 0.02°C/min; P < .001). The TS offered a greater cooling rate than all other cooling modalities in this study, whereas EC offered a greater cooling rate than both CON and BCU (P < .0083 for all). Effect-size calculations, however, showed that EC and BCU were not clinically different. CONCLUSION: These findings provide objective evidence for selecting the most effective cooling system of those we evaluated for cooling individuals with exercise-induced hyperthermia. Nevertheless, factors other than cooling efficacy need to be considered when selecting an appropriate cooling system.

Ascending and Descending Thoracic Vertebral Arteries.

Thoracic vertebral arteries are anastomotic chains similar to cervical vertebral arteries but found at the thoracic level. Descending thoracic vertebral arteries originate from the pretransverse segment of the cervical vertebral artery and curve caudally to pass into the last transverse foramen or the first costotransverse space. Ascending thoracic vertebral arteries originate from the aorta, pass through at least 1 costotransverse space, and continue cranially as the cervical vertebral artery. This report describes the angiographic anatomy and clinical significance of 9 cases of descending and 2 cases of ascending thoracic vertebral arteries. Being located within the upper costotransverse spaces, ascending and descending thoracic vertebral arteries can have important implications during spine interventional or surgical procedures. Because they frequently provide radiculomedullary or bronchial branches, they can also be involved in spinal cord ischemia, supply vascular malformations, or be an elusive source of hemoptysis.

Focal Neurological Deficit at Onset of Aneurysmal Subarachnoid Hemorrhage: Frequency and Causes.

BACKGROUND AND AIM: Focal neurological deficit (FND) is a recognized presenting symptom of aneurysmal subarachnoid hemorrhage (SAH). However, little is known on how often aneurysmal SAH patients present with FND and what the responsible mechanisms are. The aim of this study was to examine the frequency and causes of FND at onset in aneurysmal SAH. METHODS: We reviewed the records of consecutive aneurysmal SAH patients over 5 years and identified those who presented with FND. We developed several potential mechanisms for FND based on consensus between 2 separate evaluating neurologists. We then compared the characteristics of aneurysmal SAH patients who presented with and without FND. Logistic regression models were used to assess for association of FND with poor outcome. RESULTS: Of a total of 213 patients, 10.3% presented with FND. The junction of the internal carotid and posterior communicating arteries was the most common aneurysm location in patients with FND (36.4%). Causes of FND at presentation were intraparenchymal hematoma in 45.5%, early cerebral infarction in 22.7%, parenchymal compression by subarachnoid thrombus in 18.2%, and seizure with Todd's paralysis in 13.6%. Patients with FND were older (P = .001) and had higher rates of in-hospital death and severe disability at discharge (P < .0001), compared to those without focal deficit. FND was independently associated with poor outcome (odds ratio: 4.62, confidence interval: 1.41-15.14; P = .01). CONCLUSION: One in every 10 aneurysmal SAH patients presents with FND. FND at presentation has diverse mechanisms, is not associated with a specific aneurysm location, and is independently associated with poor outcome.