Background Subtraction Angiography with Deep Learning Using Multi-frame Spatiotemporal Angiographic Input.

Catheter Digital Subtraction Angiography (DSA) is markedly degraded by all voluntary, respiratory, or cardiac motion artifact that occurs during the exam acquisition. Prior efforts directed toward improving DSA images with machine learning have focused on extracting vessels from individual, isolated 2D angiographic frames. In this work, we introduce improved 2D + t deep learning models that leverage the rich temporal information in angiographic timeseries. A total of 516 cerebral angiograms were collected with 8784 individual series. We utilized feature-based computer vision algorithms to separate the database into "motionless" and "motion-degraded" subsets. Motion measured from the "motion degraded" category was then used to create a realistic, but synthetic, motion-augmented dataset suitable for training 2D U-Net, 3D U-Net, SegResNet, and UNETR models. Quantitative results on a hold-out test set demonstrate that the 3D U-Net outperforms competing 2D U-Net architectures, with substantially reduced motion artifacts when compared to DSA. In comparison to single-frame 2D U-Net, the 3D U-Net utilizing 16 input frames achieves a reduced RMSE (35.77 ± 15.02 vs 23.14 ± 9.56, p < 0.0001; mean ± std dev) and an improved Multi-Scale SSIM (0.86 ± 0.08 vs 0.93 ± 0.05, p < 0.0001). The 3D U-Net also performs favorably in comparison to alternative convolutional and transformer-based architectures (U-Net RMSE 23.20 ± 7.55 vs SegResNet 23.99 ± 7.81, p < 0.0001, and UNETR 25.42 ± 7.79, p < 0.0001, mean ± std dev). These results demonstrate that multi-frame temporal information can boost performance of motion-resistant Background Subtraction Deep Learning algorithms, and we have presented a neuroangiography domain-specific synthetic affine motion augmentation pipeline that can be utilized to generate suitable datasets for supervised training of 3D (2d + t) architectures.

Beyond the surface: analyzing etomidate and propofol as anesthetic agents in electroconvulsive therapy-A systematic review and meta-analysis of seizure duration outcomes.

Background: Electroconvulsive therapy (ECT) is a widely used treatment for severe psychiatric disorders such as schizophrenia, depression, and mania. The procedure involves applying brief electrical stimulation to induce a seizure, and anesthesia is used to ensure sedation and muscle relaxation. Finding the right anesthetic agent with minimal side effects, especially on seizure duration, is crucial for optimal outcomes because seizure duration is an important factor in the effectiveness of ECT, but the anesthetic agents used can affect it. Objective: This systematic review and meta-analysis aimed to pool the results of all relevant studies comparing the two induction agents, etomidate and propofol, for motor and electroencephalogram (EEG) seizure duration outcomes. Methods: A comprehensive literature search was conducted in the PubMed, Medline, and Cochrane Library databases to identify the relevant articles. The primary outcome measures were motor and EEG seizure durations. Statistical power was ensured by performing heterogeneity, publication bias, sensitivity analysis, and subgroup analysis. Standard mean difference and 95% confidence intervals were calculated for continuous outcomes, and a random-effects model was used. Results: A total of 16 studies were included in this meta-analysis, comprising 7 randomized control trials (RCTs), 7 crossover trials, and 2 cohorts. The overall motor seizure duration was statistically significantly longer with etomidate than with propofol. The overall result for EEG seizure duration was also longer with the use of etomidate over propofol and was statistically significant. In addition, subgrouping was performed based on the study design for both outcomes, which showed insignificant results in the cohort's subgroup for both outcomes, while the RCTs and crossover subgroups supported the overall results. Heterogeneity was assessed through subgrouping and sensitivity analysis. Conclusion: Our meta-analysis found that etomidate is superior to propofol in terms of motor and EEG seizure duration in ECT, implying potentially better efficacy. Hence, etomidate should be considered the preferred induction agent in ECT, but larger studies are needed to further validate our findings.

Synchronous Presentation of Right Parotid Branchial Cleft Cyst and Left Neck HPV-Associated Cystic Metastatic Squamous Cell Carcinoma: A Diagnostic Quandary.

Branchial cleft cyst arising within the parotid space is considered an extremely rare phenomenon. In contrast, cystic squamous cell carcinoma in the lateral neck is not an uncommon presentation of HPV-related head and neck cancer. Although they have singly been narrated in literature, simultaneous expression of these anomalies has yet to be reported. We describe a case of synchronous presentation of branchial cleft cyst of the right parotid gland and cystic metastatic squamous cell carcinoma of the left neck. These findings are discussed in light of the challenges in fine needle aspiration biopsy of cystic masses, and the risk of two distinct pathologic entities presenting as cysts in the head and neck.

Infected Ruptured Parathyroid Cyst Presenting with Hypercalcemia and Airway Obstruction: A Case Report.

Parathyroid cysts (PC) are infrequently encountered and characterize less than 1% of all head and neck masses. When present, PCs may present as a palpable neck mass and lead to hypercalcemia and rarely respiratory depression. Furthermore, the diagnostics of PCs is difficult as they can masquerade as a thyroid or mediastinal mass given their proximity. PCs are theorized to be a progression of parathyroid adenomas and often routine surgical excision is sufficient for cure. To our knowledge, there is no documented report of a patient with an infected parathyroid cyst that led to severe dyspnea. This case describes our experience of a patient with an infected parathyroid cyst presenting as hypercalcemia and airway obstruction.

Early and late recurrent cardiovascular events among high-risk patients with an acute coronary syndrome: Meta-analysis of phase III studies and implications on trial design.

BACKGROUND: Despite low-density lipoprotein cholesterol-lowering therapies and other standard-of-care therapy, there remains a substantial residual atherosclerotic risk among patients with an acute coronary syndrome (ACS). This study aims to estimate the risk of early and late recurrent major adverse cardiovascular events (MACE) and address its implications on trial design. METHODS: A literature search was performed to collect phase III interventional trials on high-risk ACS patients. Pooled event rates at 90 and 360 days were estimated by fitting random-effects models using the DerSimonian-Laird method. Under the assumption of a total sample size of 10,000 and 1:1 allocation at a one-sided alpha of 0.025 using the log-rank test, the relationship between power and relative risk reduction (RRR) or absolute risk reduction (ARR) was explored for early versus late MACE endpoint. RESULTS: Seven trials representing 82,727 recent ACS patients were analyzed. The pooled rates of recurrent MACE were 4.1% and 8.3% at 90 and 360 days. Approximately 49% of events occurred within the first 90 days. Based on the estimated risks at 90 and 360 days, to attain 90% statistical power, a lower magnitude of RRR is required for late MACE than early MACE (22% vs. 30%), whereas a lower magnitude of ARR is required for early MACE than late MACE (1.2% vs. 1.8%). CONCLUSION: The initial 90-day window after ACS represents a vulnerable period for recurrent events. From a trial design perspective, determining a clinically important benefit by RRR versus ARR may influence the decision between early and late MACE as the study endpoint.

Mining Major Transitions of Chronic Conditions in Patients with Multiple Chronic Conditions.

OBJECTIVES: Evolution of multiple chronic conditions (MCC) follows a complex stochastic process, influenced by several factors including the inter-relationship of existing conditions, and patient-level risk factors. Nearly 20% of citizens aged 18 years and older are burdened with two or more (multiple) chronic conditions (MCC). Treatment for people living with MCC currently accounts for an estimated 66% of the Nation's healthcare costs. However, it is still not known precisely how MCC emerge and accumulate among individuals or in the general population. This study investigates major patterns of MCC transitions in a diverse population of patients and identifies the risk factors affecting the transition process. METHODS: A Latent regression Markov clustering (LRMCL) algorithm is proposed to identify major transitions of four MCC that include hypertension (HTN), depression, Post- Traumatic Stress Disorder (PTSD), and back pain. A cohort of 601,805 individuals randomly selected from the population of Iraq and Afghanistan war Veterans (IAVs) who received VA care during three or more years between 2002-2015, is used for training the proposed LRMCL algorithm. RESULTS: Two major clusters of MCC transition patterns with 78% and 22% probability of membership respectively were identified. The primary cluster demonstrated the possibility of improvement when the number of MCC is small and an increase in probability of MCC accumulation as the number of co- morbidities increased. The second cluster showed stability (no change) of MCC overtime as the major pattern. Age was the most significant risk factor associated with the most probable cluster for each IAV. CONCLUSIONS: These findings suggest that our proposed LRMCL algorithm can be used to describe and understand MCC transitions, which may ultimately allow healthcare systems to support optimal clinical decision- making. This method will be used to describe a broader range of MCC transitions in this and non-VA populations, and will add treatment information to see if models including treatments and MCC emergence can be used to support clinical decision-making in patient care.

Practical perioperative pinnaplasty preparation.

Creating and maintaining a sterile operative field for pinnaplasty can be difficult. Drapes can slip, and stray hairs can interfere with delicate dissection and suturing. Methods to combat this have been suggested in the literature, but each has disadvantages, either in cost or in adequacy of surgical access. This report describes a practical and prudent technique for reducing contamination and obstruction by stray hairs in the operative field during performance of a pinnaplasty while maintaining adequate access at no added cost.

CASE REPORT Playing Football Burns More Than Just Calories.

OBJECTIVE: To highlight the case of a sports-related alkali burn due to a common household chemical and emphasize the importance of a detailed medical history in chemical burns patients. METHODS: A single-patient case study is presented along with references from existing literature. RESULTS: Alkaline burn injuries associated with sports have previously been described in the literature; however, this case demonstrates an unusual presentation of a chemical burn with a readily available household substance. CONCLUSION: Chemical burns can present in atypical ways. Detailed history and thorough clinical examination is essential in determining the correct diagnosis and therefore implementing the most appropriate management plan.

Liver derived pro-inflammatory cytokines may be important in producing intracranial hypertension in acute liver failure.

We describe a patient with paracetamol induced acute liver failure (ALF) who fulfilled criteria for poor prognosis and was waiting for a liver to become available for transplantation. Because of severe uncontrolled intracranial hypertension she underwent a hepatectomy that resulted in stabilization of her systemic and cerebral hemodynamics. She remained anhepatic for 14 h and was successfully bridged to liver transplantation. The removal of the liver was associated with a sharp and sustained reduction in the circulating pro-inflammatory cytokine concentration suggesting that liver derived pro-inflammatory cytokines may be important in the pathogenesis of intracranial hypertension in patients with ALF.

Holmium:YAG laser treatment of recurrent superficial bladder carcinoma: initial clinical experience.

PURPOSE: To review our initial experience with the holmium laser in patients with recurrent superficial bladder cancer. PATIENTS AND METHODS: We treated 41 patients having 71 recurrent superficial transitional-cell tumors of the bladder between December 1994 and September 1997 using the holmium:YAG laser under local anesthesia. The laser treatment was carried out as a part of the follow-up flexible cystoscopy protocol, and topical anesthesia was used. The mean follow-up was 14 months (range 3-33 months). RESULTS: There were 13 recurrent tumors in the treated area and 38 recurrences in the untreated areas. Of interest, a subgroup of 10 patients were treated before 1994 with cystodiathermy and later on with the holmium:YAG laser at various times during their follow-up. The local recurrence rate with cystodiathermy was 32% compared with 10% after laser treatment (P = 0.39). A questionnaire study of 33 patients showed complete satisfaction with the treatment. Only 2 (6%) elected to have a further procedure under general anesthesia. In the series, 83% scored their pain as 2 or less of 10 on a visual analog scale. CONCLUSIONS: The absence of complications, high patient satisfaction, and ability to be used in the outpatient setting make the holmium:YAG laser an attractive alternative in the treatment of recurrent superficial cancer of the bladder.

Diversion colitis in children with colovaginoplasty.

OBJECTIVE: To highlight the occurrence of diversion colitis and its effects in colovaginoplasty. Patients and methods The records of 18 children who had undergone colovaginoplasty were reviewed retrospectively. Nine patients had androgen-insensitivity syndrome and three each had congenital adrenal hyperplasia, vaginal agenesis and Mayer-Rokitansky syndrome. Through an abdominoperineal approach a segment of sigmoid colon was isolated on its vascular pedicle and brought to the perineum in the plane between the urethra and rectum, as a blind pouch or as an interposition between the proximal vagina and the perineum. The mean (range) follow-up was 5 (1.5-8) years. RESULTS: There were no major complications during the early follow-up. Three patients developed severe vaginal discharge with bleeding 2-7 years after colovaginoplasty; examination showed erythema, oedema, ulceration and bleeding. Histology confirmed the classic features of diversion colitis in all three patients. One child responded to vaginal irrigation with a solution of short-chain fatty acids, and the other two were treated with steroid enemas and mesalazine after a poor response to short-chain fatty acids. One of these patients has required surgical reduction of an excessively long neovagina. Conclusion Symptomatic diversion colitis can occur after colovaginoplasty. The severity of the symptoms raises concerns about the use of colovaginoplasty in children and alternative techniques of vaginal replacement should be considered in the first instance.