Appearance of intracranial cottonoids on intraoperative magnetic resonance imaging.

To our knowledge, this is a unique report of intraoperative magnetic resonance imaging (iMRI) of an intracranial cottonoid. The current literature describes images of cottonoids as a post-operative finding in the setting of an unintentionally retained foreign body; however, the iMRI images we present are important as the use of iMRI in the resection of complex tumors and epilepsy foci increases. This series of images was obtained during a craniotomy for tumor resection of a patient with dysembryoplastic neuroepithelial tumor. To determine both the degree of tumor resection and the amount of residual tumor, cottonoids were left in our patient's resection cavity and underwent iMRI. The ability to distinguish cottonoids in these images is important for intraoperative localization of resection margins and to prevent the retention of cottonoids.

Harvest of large fascia lata autograft: Outcomes in 108 patients.

PURPOSE: Due to the reclassification of transvaginal mesh as a high-risk device, there has been renewed interest in the use of fascia lata in pelvic floor reconstruction. Here we report our experience in 108 patients who underwent large fascia lata harvest for pelvic organ prolapse (POP) repair. Our primary objective was to highlight the postoperative morbidity of the large fascia lata harvest in patients who underwent POP repair using fascia lata autograft. METHODS: Surgery involved harvesting a fascia lata graft through a small lateral upper thigh incision and was used for either autologous transvaginal POP repair or autologous sacrocolpopexy. To prevent seroma, a temporary Jackson-Pratt drain was intraoperatively placed and a mild compression wrap was applied to the area for 4-6 weeks postoperatively. Patient demographics were obtained preoperatively, while physical exam findings and postoperative outcomes related to the fascia lata harvest were collected at sequential follow up visits. RESULTS: One-hundred eight patients underwent 111 large fascia lata harvests for either transvaginal or abdominal/robotic POP repair from July 2016 to January 2022. Mean follow-up was 19.6 months (range: 1-65) with 38 patients having 24 months or more of follow-up. Mean Visual Analog Pain (VAP) score was 1 (range: 0-10). Sixteen patients developed asymptomatic thigh bulges, 16 patients developed harvest site seromas (of which 14 resolved), and 59 patients experienced mild, non-bothersome paresthesia near the incision. CONCLUSION: Large fascia lata harvest offers a robust autograft for transvaginal or transabdominal POP repair with minimal morbidity. Harvest site complications are minor and typically resolve with expectant management. This technique can be safely utilized in patients who desire graft-augmented repair of POP without the use of synthetic mesh, allograft, or xenograft.

Interpreting a Delayed Workup of Idiopathic Inflammatory Myopathy.

Idiopathic inflammatory myopathies are a widely heterogeneous group of muscle diseases and encompass multiple clinicopathologic entities. Our case presentation describes a 70-year-old male who presented with progressively worsening dyspnea, along with worsening proximal muscle weakness in the bilateral lower extremities. Extensive clinical evaluation revealed a creatine kinase level of 105 IU/L, severe and chronic widespread myopathy seen on electromyography (EMG), and asymmetric but widespread muscle atrophy with fibro-fatty replacement seen on ultrasonography. Muscle biopsy specimen from the left deltoid was suboptimal but demonstrated characteristics that could be consistent with several clinicopathologic diagnoses, including sporadic inclusion body myositis (sIBM), immune-mediated necrotizing myositis (IMNM), antisynthetase syndrome (AS), and direct toxin-induced myopathy. Electron microscopy revealed tubulofilamentous inclusion associated with autophagic debris, finally rendering an accurate diagnosis. This case summary highlights the testing workflow required to diagnose a patient with an inflammatory myopathy and outlines the difficulty in establishing a diagnosis when the workup for an inflammatory myopathy is delayed and the muscle biopsy is suboptimal.

County-level variation in healthcare coverage and ischemic heart disease mortality.

BACKGROUND: Healthcare coverage has been shown to have implications in the prevalence of coronary artery disease. We explore the impact of lack of healthcare coverage on ischemic heart disease (IHD) mortality in the US. METHODS: We obtained county-level IHD mortality and healthcare coverage data from the CDC databases for a total of 3,119 US counties. The age-adjusted prevalence of current lack of health insurance among individuals aged 18 to 64 years were obtained for the years 2018 and 2019 and were placed into four quartiles. First (Q1) and fourth quartile (Q4) had the least and highest age-adjusted prevalence of adults without health insurance, respectively. IHD mortality rates, adjusted for age through the direct method, were obtained for the same years and compared among quartiles. Ordinary least squares (OLS) regression for each demographic variable was conducted with the quartiles as an ordinal predictor variable and the age-adjusted mortality rate as the outcome variable. RESULTS: We identified a total of 172,942 deaths related to ischemic heart disease between 2018 and 2019. Overall AAMR was higher in Q4 (92.79 [95% CI, 92.35-93.23]) compared to Q1 (83.14 [95% CI, 82.74-83.54]), accounting for 9.65 excess deaths per 100,000 person-years (slope = 3.47, p = 0.09). Mortality rates in Q4 for males (126.20 [95% CI, 125.42-126.98] and females (65.57 [95% CI, 65.08-66.05]) were higher compared to Q1 (115.72 [95% CI, 114.99-116.44] and 57.48 [95% CI, 57.04-57.91], respectively), accounting for 10.48 and 8.09 excess deaths per 100,000 person-years for males and females, respectively. Similar trends were seen among Hispanic and non-Hispanic populations. Northeastern, Southern, and Western regions had higher AAMR within Q4 compared to Q1, with higher prevalence of current lack of health insurance accounting for 49.2, 8.15, and 29.04 excess deaths per 100,000 person-years, respectively. CONCLUSION: A higher prevalence of adults without healthcare coverage may be associated with increased IHD mortality rates. Our results serve as a hypothesis-generating platform for future research in this area.

What Is Going on in Our Schools? Review of Injuries Among School Children Across the United States.

INTRODUCTION: Children spend most of their time at school and participate in many activities that have the potential for causing injury. This study aims to describe the nationwide epidemiology of pediatric trauma sustained in school settings in the United States. METHODS: In the 3-y analysis of 2017-2019 American College of Surgeons-Trauma Quality Program, all pediatric trauma patients (≤18 y) injured in a school setting were included and stratified based on place of injury, into elementary, middle, and high school (HS) groups. Descriptive statistics and multivariable logistic regression analysis were performed to identify the independent predictors of intentional injuries. RESULTS: 23,215 pediatric patients were identified, of which 15,264 patients were injured at elementary (57.6%), middle (17.5%), and high (25%) schools. The mean age was 9.5 y, 66.9% were male, 63.9% were white, the median injury severity score was 2 [1-4], and 95.6% had a blunt injury. Elementary school students were more likely to sustain falls (85%) and humerus fractures (43%) whereas HS students were more likely to be injured by assaults (17%). Overall, 7% of the students sustained intentional injuries. On multivariable logistic regression, male gender (odds ratio [OR] 1.54), Black race (OR 2.94), American Indian race (OR 1.88), Hispanic ethnicity (OR 1.77), positive drug screen (OR 4.9), middle (OR 5.2), and HSs (OR 10.6) were identified as independent predictors of intentional injury (all P < 0.01). CONCLUSIONS: Injury patterns vary across elementary, middle, and HSs. Racial factors appear to influence intentional injuries along with substance abuse. Further studies to understand these risk factors and efforts to reduce school injuries are warranted to provide a safe learning environment for children.

Naturopathic Treatment of Grade III Oligodendroglioma With Progression to Grade IV Isocitrate Dehydrogenase (IDH)-Mutant Astrocytoma and the Development of Spinal Gliomatosis.

Primary intracranial gliomas are a heterogeneous class of lesions that rarely metastasize. Even more infrequently, they may spread caudally into the spinal cord causing spinal gliomatosis. In this case, we discuss an 18-year-old male patient with a diagnosis of grade IV astrocytoma with spinal gliomatosis, specifically detailing the radiographic progression of the disease over 38 months. We also discuss the significance of the change in the WHO classification of central nervous system tumors, as this patient's survival duration is inconsistent with the low survival rates expected of glioblastoma, and rather more consistent with a grade IV astrocytoma.

Integrating evidence-based medicine into resident education.

Evidence-based medicine (EBM) is the practice of applying scientific evidence to clinical decision-making, with a focus on addressing the individualized needs and values of patients. It requires not only a solid foundation of medical knowledge and the ability to gather a thorough patient history but also the skills to locate, interpret, and apply relevant principles from the medical literature. Given the rapid advancements in the field of medicine, understanding medical literature holds significant importance for residents during their education and future careers. It is particularly crucial for reducing medical waste, adhering to guidelines, and decreasing morbidity and mortality rates. This paper aims to underscore the significance of increasing residents' exposure to evidence-based approaches in clinical decision-making, propose time-efficient and effective methods to enhance their understanding of EBM, and promote the implementation of evidence-based practices within the inpatient setting.

Enlarging traumatic superficial temporal artery pseudoaneurysm from a lacrosse ball injury: illustrative case.

BACKGROUND: The development of a mobile, growing, pulsatile mass after blunt head trauma to the forehead area, resulting in a superficial temporal artery pseudoaneurysm, is a very rare outcome. Most pseudoaneurysms are diagnosed with ultrasound, computed tomography (CT), and/or magnetic resonance imaging and treated via resection or, occasionally, embolization. OBSERVATIONS: The authors describe a case of a young male lacrosse player who presented with a bulging, partially pulsatile mass in the right forehead region 2 months after trauma from a high-velocity ball striking his head while helmeted. The authors reviewed 12 patients in the literature and describe each patient's epidemiological features, nature of the trauma, and onset of the lesion after the trauma, as well as the diagnostic methods and treatments for each case. LESSONS: Overall, CT and ultrasound appear to be the easiest and most used methods of diagnosis, and resection under general anesthesia is the most common treatment method.

KCCQ total symptom score, clinical outcome measures, and adverse events associated with omecamtiv mecarbil for heart failure with reduced ejection fraction: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Omecamtiv mecarbil (OM) is a direct myosin activator that augments left ventricular systolic function. This review compares OM to placebo by evaluating its effect on clinical outcomes and adverse events in patients with heart failure with reduced left ventricular ejection fraction. METHODS AND RESULTS: A literature search of multiple databases for randomized controlled trials (RCTs) investigating OM versus placebo was undertaken. Six RCTs comprising 9596 patients were included. Use of OM was associated with a reduced risk of stroke (RR: 0.69; 95% CI 0.52-0.92). There was no significant mean difference (MD) change in the KCCQ total symptom score (MD: 1.82, 95% CI - 1.33 to 4.97), all-cause death (RR: 1.00; 95% CI 0.93-1.07), hospital readmissions (RR: 0.96; 95% CI 0.90-1.03), myocardial infarction (RR: 1.05; 95% CI 0.83-1.33), cardiovascular death (RR: 1.01; 95% CI 0.92-1.10), heart failure (HF) events (RR: 0.95; 95% CI 0.89-1.02), or a composite of cardiovascular death or HF events (RR: 0.97; 95% CI 0.93-1.02). In addition, OM was associated with an increased risk of dizziness (RR: 1.25; 95% CI 1.04-1.50) and hypotension (RR: 1.17; 95% CI 1.01-1.36). Other adverse events including ventricular tachyarrhythmias, (RR: 0.95; 95% CI 0.82-1.11), supraventricular tachyarrhythmias and atrial fibrillation/flutter (RR: 0.73; 95% CI 0.46-1.18), dyspnea (RR: 1.00; 95% CI 0.86-1.18), and acute renal injury (RR: 0.88; 95% CI 0.60-1.27) were not significant. CONCLUSION: OM is generally well tolerated. We identified a reduced risk of stroke with use of OM. However, there was no improvement in other clinical outcomes or quality of life. Study protocol was registered in PROSPERO international prospective register of systematic reviews (CRD42022348423).