Pulmonary artery involvement in Behçet's disease: A challenging case and comprehensive management approach.

A 26-year-old male with Behçet's disease (BD) presented with recurrent oral and genital ulcers, bilateral pneumonia, and a left lower pulmonary artery aneurysm. Endovascular coil embolization was initially performed, followed by treatment with prednisone, colchicine, and azathioprine. Despite treatment, disease progression occurred, requiring additional embolization, intravenous pulse methylprednisolone, and cyclophosphamide. Ultimately, a combination of medical and endovascular interventions resolved the pulmonary arterial aneurysms. This case highlights BD's systemic inflammatory nature and vascular complications like pulmonary artery aneurysms. It emphasizes the importance of early detection and individualized, multidisciplinary care for such complications.

A complicated presentation of vertebral coccidioidomycosis dissemination: A case report and discussion.

Coccidioidomycosis, also known as San Joaquin Valley fever, is an illness caused by the dimorphic fungus Coccidioides. Coccidioidomycosis is endemic to desert regions of the Western Hemisphere, including California, Arizona, Utah, Nevada, and New Mexico. We report a case of disseminated coccidioidomycosis in a 42-year-old male. Months after an upper respiratory infection of unidentified origin, the patient began experiencing back pain. The persistence of the back pain prompted MRI and CT imaging, which revealed lytic lesions. His clinical and radiological presentation mimicked, and was originally approached, as if it were a malignancy. Metastasis or multiple myeloma were considered the most likely differential diagnoses. As a result, the patient underwent surgical exploration. Pathology results indicated the presence of a fungal infection, without evidence of malignancy. PCR confirmed the diagnosis of coccidioidomycosis. The patient began treatment with fluconazole 800 mg daily and is anticipated to receive antifungal treatment for an indefinite period.

Aplastic Internal Carotid Artery: A Potentially Catastrophic Vascular Anomaly.

Congenital absence of an internal carotid artery (ICA) is a rare vascular anomaly and occurs in less than 0.01% of the population. We report a case of aplastic internal carotid artery in a 34-year-old female. The patient presented to the emergency department with complaints of new-onset involuntary swaying-like movement of her right arm. Brain magnetic resonance imaging showed multifocal tiny areas of acute infarcts in the bilateral frontal, parietal, and left occipital lobes in the watershed distribution. There was no visualization of the flow of the intracranial left internal carotid artery. Follow-up CTA of the head and neck showed a congenital absence of the left internal carotid artery with no evidence of arterial dissection, occlusion, or aneurysm. Obstruction of the internal carotid artery has significant consequences for patients. This effect is amplified if the disruption occurs in the sole anterior blood supply to the parenchyma of the brain, as in this case. In our patient care, imaging was vital to the detection and subsequent treatment with anticoagulation to avoid further cerebral complications, and the patient will now have a better understanding of the increased lifetime risk of further events.

Colostrum and Preterm Babies: A Systematic Review.

Colostrum from mothers is rich in immunomodulating bio-factors such as immunoglobulins (IgA), lactoferrin, and oligosaccharides and supports gut microbial and inflammatory processes. The support in these processes may provide some relief for infants who are born pre-term. Pre-term infants are more likely to develop necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and ventilator-acquired/associated pneumonia (VAP). Due to the components of colostrum, there may be incentives towards early administration for preterm infants. An extensive literature review was done using ProQuest, ScienceDirect, and PubMed. Only meta-analyses and experimental studies were used. The search included the keywords 'colostrum and preterm' and 'colostrum and necrotizing enterocolitis'. The initial search generated 13,543 articles and was narrowed to 25 articles through comprehensive inclusion and exclusion criteria. There were significantly higher levels of Lactobacillus and Bifidobacterium in pre-term infants given colostrum and a decrease in Moraxellaceae and Staphylococcaceae. Salivary secretory IgA increased following oral colostrum administration in pre-term infants along with downregulation of interleukin (IL)-1b and IL-8. It was also observed that tumor necrosis factor (TNF)-a, and interferon-gamma (IFN-g) were significantly higher in the control group. There was no significant difference in the incidence of LOS, NEC, or VAP between pre-term infants receiving colostrum and those who did not. Secondary outcomes such as time to full enteral feeding were improved in pre-term infants receiving oral colostrum in addition to reduced hospital stays. Lastly, there was no difference in mortality between pre-term infants that received colostrum compared to those who did not.

Anti-inflammatory medication use associated with reduced delirium risk and all-cause mortality: A retrospective cohort study.

OBJECTIVE: To investigate the relationship between history of anti-inflammatory medication use and delirium risk, as well as long-term mortality. METHODS: In this retrospective cohort study, subjects recruited between January 2016 and March 2020 were analyzed. Information about anti-inflammatory medication use history including aspirin, NSAIDs, glucosamine, and other anti-inflammatory drugs, was collected. Logistic regression analysis investigated the relationship between anti-inflammatory medications and delirium. Log-rank analysis and cox proportional hazards model investigated the relationship between anti-inflammatory medications and one-year mortality. RESULTS: The data from 1274 subjects were analyzed. The prevalence of delirium was significantly lower in subjects with NSAIDs usage (23.0%) than in those without NSAIDs usage (35.0%) (p < 0.001). Logistic regression analysis controlling for age, sex, dementia status, and hospitalization department showed that the risk of delirium tended to be reduced by a history of NSAIDs use (OR, 0.76 [95% CI, 0.55 to 1.03]). The one-year mortality in the subjects with NSAIDs (survival rate, 0.879 [95% CI, 0.845 to 0.906]) was significantly lower than in the subjects without NSAIDs (survival rate, 0.776 [95% CI, 0.746 to 0.803]) (p < 0.001). A history of NSAIDs use associated with the decreased risk of one-year mortality even after adjustment for age, sex, Charlson Comorbidity Index, delirium status, and hospitalization department (HR, 0.70 [95% CI, 0.51 to 0.96]). CONCLUSION: This study suggested that NSAIDs usage was associated with decreased delirium prevalence and lower one-year mortality. The potential benefit of NSAIDs on delirium risk and mortality were shown.

Metformin use history and genome-wide DNA methylation profile: potential molecular mechanism for aging and longevity.

BACKGROUND: Metformin, a commonly prescribed anti-diabetic medication, has repeatedly been shown to hinder aging in pre-clinical models and to be associated with lower mortality for humans. It is, however, not well understood how metformin can potentially prolong lifespan from a biological standpoint. We hypothesized that metformin's potential mechanism of action for longevity is through its epigenetic modifications. METHODS: To test our hypothesis, we conducted a post-hoc analysis of available genome-wide DNA methylation (DNAm) data obtained from whole blood collected from inpatients with and without a history of metformin use. We assessed the methylation profile of 171 patients (first run) and only among 63 diabetic patients (second run) and compared the DNAm rates between metformin users and nonusers. RESULTS: Enrichment analysis from the Kyoto Encyclopedia of Genes and Genome (KEGG) showed pathways relevant to metformin's mechanism of action, such as longevity, AMPK, and inflammatory pathways. We also identified several pathways related to delirium whose risk factor is aging. Moreover, top hits from the Gene Ontology (GO) included HIF-1α pathways. However, no individual CpG site showed genome-wide statistical significance (p < 5E-08). CONCLUSION: This study may elucidate metformin's potential role in longevity through epigenetic modifications and other possible mechanisms of action.

Traumatic Pseudoaneurysms of the Internal Mammary Artery: Two Cases and Percutaneous Intervention.

Pseudoaneurysms involving the internal mammary artery/internal thoracic artery (IMA/ITA) are rare occurrences, and the presentation and treatment approaches for such cases can be variable. Due to the potentially life-threatening risk of rupture, leading to conditions like hemothorax, it is important to have a comprehensive understanding of safe and effective diagnostic and therapeutic techniques. We present two cases of IMA/ITA artery pseudoaneurysms. A 91-year-old male presented to the emergency department following a motor vehicle accident. A CT scan of the chest revealed an anterior mediastinal hemorrhage with active extravasation. Percutaneous intervention revealed a pseudoaneurysm arising from a left IMA/ITA side branch. Coil embolization effectively treated the pseudoaneurysm. In the second case, a 79-year-old male presented with a sternal fracture after a ground-level fall, with parasternal hematoma and active bleeding (pseudoaneurysm) on Trauma Computerized Tomography of the chest with contrast. He underwent coil embolization, and subsequent post-procedure angiograms confirmed the effective occlusion of the left IMA/ITA, with no further visualization of the pseudoaneurysm. These two cases underscore the importance of tailored approaches in treating internal mammary artery pseudoaneurysms.

The potential benefit of metformin to reduce delirium risk and mortality: a retrospective cohort study.

PURPOSE: Metformin has been reported to improve age-related disorders, including dementia, and to lower mortality. This study was conducted to investigate whether metformin use lower delirium risk, as well as long-term mortality. METHODS: In this retrospective cohort study, previously recruited 1,404 subjects were analyzed. The relationship between metformin use and delirium, and the relationship between metformin use and 3-year mortality were investigated. MAIN FINDINGS: 242 subjects were categorized into a type 2 diabetes mellitus (DM)-without-metformin group, and 264 subjects were categorized into a DM-with-metformin group. Prevalence of delirium was 36.0% in the DM-without-metformin group, and 29.2% in the DM-with-metformin group. A history of metformin use reduced the risk of delirium in patients with DM (OR, 0.50 [95% CI, 0.32 to 0.79]) after controlling for confounding factors. The 3-year mortality in the DM-without-metformin group (survival rate, 0.595 [95% CI, 0.512 to 0.669]) was higher than in the DM-with-metformin group (survival rate, 0.695 [95% CI, 0.604 to 0.770]) (p=0.035). A history of metformin use decreased the risk of 3-year mortality after adjustment for confounding factors (HR, 0.69 [95% CI, 0.48 to 0.98]). CONCLUSIONS: Metformin use may lower the risk of delirium and mortality in DM patients.

Osteochondral Allograft Transplantation Of Posterior Femoral Condyle Lesions Utilizing An Open Posterior Approach To The Knee.

Osteochondral allograft transplantation is a viable option for large chondral defects >2 cm squared, as well as in a revision setting after failure of a previous surface chondral restoration procedure. Osteochondral lesions involving the posterior aspect of the femoral condyle, however, are less common and easily underappreciated. Treatment of posterior osteochondral lesions is more technically demanding because they cannot be adequately addressed through standard arthroscopic approaches or an anterior arthrotomy. The challenges of the posterior approach include the relative unfamiliarity for many surgeons and the inherent risks due to the proximity of the neurovascular structures. The following technique reviews relevant anatomy and approach to osteochondral allograft transplant involving the posterior femoral condyles.

2D versus 3D Endoscopy: Head-to-Head Comparison in a Simulated Model of Endoscopic Endonasal Dural Suturing.

Objective Endonasal dural suturing (EDS) has been reported to decrease the incidence of cerebrospinal fluid fistula. This technique requires handling of single-shaft instrumentation in the narrow endonasal corridor. It has been proposed that three-dimensional (3D) endoscopes were associated with improved depth perception. In this study, we sought to perform a comparison of two-dimensional (2D) versus 3D endoscopy by assessing surgical proficiency in a simulated model of EDS. Materials and Methods Twenty-six participants subdivided into groups based on previous endoscopic experience were asked to pass barbed sutures through preset targets with either 2D (Storz Hopkins II) or 3D (Storz TIPCAM) endoscopes on 3D-printed simulation model. Surgical precision and procedural time were measured. All participants completed a Likert scale questionnaire. Results Novice, intermediate, and expert groups took 11.0, 8.7, and 5.7 minutes with 2D endoscopy and 10.9, 9.0, and 7.6 minutes with 3D endoscopy, respectively. The average deviation for novice, intermediate, and expert groups (mm) was 5.5, 4.4, and 4.3 with 2D and 6.6, 4.6, and 3.0 with 3D, respectively. No significant difference in procedural time or accuracy was found in 2D versus 3D endoscopy. 2D endoscopic visualization was preferred by the majority of expert/intermediate participants, while 3D endoscopic visualization by the novice group. Conclusion In this pilot study, there was no statistical difference in procedural time or accuracy when utilizing 2D versus 3D endoscopes. While it is possible that widespread familiarity with 2D endoscopic equipment has biased this study, preliminary analysis suggests that 3D endoscopy offers no definitive advantage over 2D endoscopy in this simulated model of EDS.

Primary Dural Repair via an Endoscopic Endonasal Corridor: Preliminary Development of a 3D-Printed Model for Training.

Objectives Endonasal suturing is an investigational method for dural repair that has been reported to decrease the incidence of cerebrospinal fluid fistula. This method requires handling of single-shaft instrumentation in the narrow endonasal corridor. In this study, we designed a low-cost, surgical model using three-dimensional (3D) printing technology to simulate dural repair through the endonasal corridor and subsequently assess the utility of the model for surgical training. Methods Using an Ultimaker 2+ printer, a 3D-printed replica of the cranial base and nasal cavity was fitted with tissue allograft to recapitulate the dural layer. Residents, fellows, and attending surgeons were asked to place two sutures using a 0-degree endoscope and single-shaft needle driver. Task completion time was recorded. Participants were asked to fill out a Likert scale questionnaire after the experiment. Results Twenty-six participants were separated into groups based on their prior endoscope experience: novice, intermediate, and expert. Twenty-one (95.5%) residents and fellows rated the model as "excellent" or "good" in enhancing their technical skills with endoscopic instrumentation. Three of four (75%) of attendings felt that the model was "excellent" or "good" in usefulness for training in dural suturing. Novice participants required an average of 11 minutes for task completion, as compared with 8.7 minutes for intermediates and 5.7 minutes for experts. Conclusion The proposed model appears to be highly effective in enhancing the endoscopic skills and recapitulating the task of dural repair. Such a low-cost model may be especially important in enhancing endoscopic facility in countries/regions with limited access to cadaveric specimens.

Electrospinning of cyanoacrylate tissue adhesives for human dural repair in endonasal surgery.

Cerebral spinal fluid (CSF) leakage is a major postoperative complication requiring surgical intervention, resulting in prolonged healing and higher costs. Biocompatible polymers, such as cyanoacrylates, are currently used as tissue adhesives for closing surgical defects and incisions. Coupling these polymers with nanofiber technology shows promising results for generating nanofibers used in wound care, tissue engineering, and drug delivery. Fiber membranes formed by electrospinning of n-octyl-2-cyanoacrylate (NOCA) are investigated for in situ dural closures after neurosurgery to improve the quality of the closure and prevent post-surgical CSF leaks. Electrospun NOCA fiber membranes showed significantly higher sealing capabilities of defects in human dura, with an average burst pressure of 149 mmHg, compared with that of an FDA-approved common dural sealant that had an average burst pressure of 37 mmHg. In this study, microfabrication of NOCA fibers demonstrates a promising technique for dural repairs.

Mortality prediction by bispectral electroencephalography among 502 patients: its role in dementia.

Complications of delirium and dementia increase mortality; however, it is difficult to diagnose delirium accurately, especially among dementia patients. The bispectral electroencephalography score can detect delirium and predict mortality in elderly patients. We aimed to develop an efficient and reliable bispectral electroencephalography device for high-throughput screening. We also hypothesized that bispectral electroencephalography score can predict mortality among dementia patients. A prospective cohort study was conducted between January 2016 and December 2018 to measure bispectral electroencephalography from elderly patients and correlate with outcomes. A total of 502 elderly (55 years old or older) patients with and without dementia were enrolled. For a replication of the utility of bispectral electroencephalography, mortalities between bispectral electroencephalography-positive and bispectral electroencephalography-negative group were compared. In addition, patients with and without dementia status were added to examine the utility of bispectral electroencephalography among dementia patients. The mortality within 180 days in the bispectral electroencephalography-positive group was higher than that of the bispectral electroencephalography-negative group in both the replication and the total cohorts. Mortality of those in the bispectral electroencephalography-positive group showed a dose-dependent increase in both cohorts. When the dementia patients showed bispectral electroencephalography positive, their mortality was significantly higher than those with dementia but who were bispectral electroencephalography-negative. Mortality within 30 days in the bispectral electroencephalography-positive group was significantly higher than that of the bispectral electroencephalography-negative group. The utility of the bispectral electroencephalography to predict mortality among large sample of 502 elderly patients was shown. The bispectral electroencephalography score can predict mortality among elderly patients in general, and even among dementia patients, as soon as 30 days.

DNA methylation in the TNF-alpha gene decreases along with aging among delirium inpatients.

It has been suggested that aging and inflammation play key roles in the development of delirium. In the present study, we investigated the differences of the DNAm patterns in the TNF gene between patients with delirium and without. The data and samples derived from previous and ongoing cohort studies were analyzed. DNAm levels of the TNF gene were analyzed using the Illumina EPIC array genome-wide method and pyrosequencing method. Correlations between age and DNAm levels of each CpG were calculated. Several CpG in the TNF gene in blood showed negative correlation between their DNAm and age in delirium cases both with the EPIC array and by the pyrosequencing method. However, there was no CpG that had significant correlation between their DNAm and age regardless of delirium status among buccal samples. On the other hand, among peripheral blood mononuclear cells samples, it was found that several CpG showed negative correlation between their DNAm and age in delirium cases. The evidence of DNAm change in the TNF gene among delirious subjects was demonstrated.

New Cutoff Scores for Delirium Screening Tools to Predict Patient Mortality.

BACKGROUND/OBJECTIVES: Detecting delirium is important to identify patients with a high risk of poor outcomes. Although many different kinds of screening instruments for delirium exist, there is no solid consensus about which methods are the most effective. In addition, it is important to find the most useful tools in predicting outcomes such as mortality. DESIGN: Retrospective cohort study. SETTING: University of Iowa Hospitals and Clinics. PARTICIPANTS: A total of 1,125 adult inpatients (mean age = 67.7; median age = 69). MEASUREMENTS: Post hoc analyses were performed based on existing data from the Confusion Assessment Method for Intensive Care Unit (CAM-ICU), Delirium Rating Scale-Revised-98 (DRS), and the Delirium Observation Screening Scale (DOSS). Correlation among these scales and relationships between 365-day mortality and each scale were evaluated. RESULTS: A positive result on the CAM-ICU ("CAM-ICU positive") was associated with higher DRS and DOSS scores. A DRS score = 9/10 was the best cutoff to detect CAM-ICU positive, and DOSS = 2/3 was the best cutoff to detect CAM-ICU positive. CAM-ICU positive was associated with high 365-day mortality. DRS score = 9/10 and DOSS score = 0/1 were found to differentiate mortality risk the most significantly. Higher DRS and DOSS scores significantly coincided with a decrease in a patient's survival rate at 365 days. CONCLUSION: The best DRS and DOSS cutoff scores to differentiate 365-day mortality risk were lower than those commonly used to detect delirium in the literature. New cutoff scores for the DRS and DOSS might be useful in differentiating risk of mortality among hospital patients.

Evaluation of point-of-care thumb-size bispectral electroencephalography device to quantify delirium severity and predict mortality.

BACKGROUND: We have developed the bispectral electroencephalography (BSEEG) method for detection of delirium and prediction of poor outcomes. AIMS: To improve the BSEEG method by introducing a new EEG device. METHOD: In a prospective cohort study, EEG data were obtained and BSEEG scores were calculated. BSEEG scores were filtered on the basis of standard deviation (s.d.) values to exclude signals with high noise. Both non-filtered and s.d.-filtered BSEEG scores were analysed. BSEEG scores were compared with the results of three delirium screening scales: the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), the Delirium Rating Scale-Revised-98 (DRS) and the Delirium Observation Screening Scale (DOSS). Additionally, the 365-day mortalities and the length of stay (LOS) in the hospital were analysed. RESULTS: We enrolled 279 elderly participants and obtained 620 BSEEG recordings; 142 participants were categorised as BSEEG-positive, reflecting slower EEG activity. BSEEG scores were higher in the CAM-ICU-positive group than in the CAM-ICU-negative group. There were significant correlations between BSEEG scores and scores on the DRS and the DOSS. The mortality rate of the BSEEG-positive group was significantly higher than that of the BSEEG-negative group. The LOS of the BSEEG-positive group was longer compared with that of the BSEEG-negative group. BSEEG scores after s.d. filtering showed stronger correlations with delirium screening scores and more significant prediction of mortality. CONCLUSIONS: We confirmed the usefulness of the BSEEG method for detection of delirium and of delirium severity, and prediction of patient outcomes with a new EEG device.

Supramolecular Interactions of Group VI Metal Carbonyl Complexes: The Facilitating Role of 1,3-Bis( p-isocyanophenyl)urea.

An investigation of supramolecular phenomena involving zerovalent transition metal complexes was facilitated by the production of the ditopic isocyanide ligand 1,3-bis( p-isocyanophenyl)urea, which was synthesized via substoichiometric phosgenation of 4-isocyanophenylamine and used to coordinate group VI metal carbonyl fragments. The resulting binuclear organometallic complexes were observed to pack into ladder-like anisotropic arrays in the solid state. Crystallographic and computational evidence suggests that this packing motif can be attributed to a combination of intermolecular π-π and urea-π interactions. Similar to other N, N'-diarylureas bearing electron-withdrawing groups, 1,3-bis( p-isocyanophenyl)urea and the organometallic complexes prepared therefrom also exhibit an affinity toward anion binding in nonaqueous solution. Equilibrium constants ( K) for the formation of host-guest complexes between the organometallic derivatives of 1,3-bis( p-isocyanophenyl)urea and chloride, nitrate, and acetate anions exceed 103, 104, and 105 M-1, respectively.

Short, Tin-Free Synthesis of All Three Inthomycins.

The inthomycins are a family of structurally and biologically rich natural products isolated from Streptomyces species. Herein the implementation of a modular synthetic route is reported that has enabled the enantioselective synthesis of all three inthomycins. Key steps include Suzuki and Sonogashira cross-couplings and an enantioselective Kiyooka aldol reaction.

NMR-based assignment of isoleucine vs. allo-isoleucine stereochemistry.

A simple 1H and 13C NMR spectrometric analysis is demonstrated that permits differentiation of isoleucine and allo-isoleucine residues by inspection of the chemical shift and coupling constants of the signals associated with the proton and carbon at the α-stereocentre. This is applied to the estimation of epimerisation during metal-free N-arylation and peptide coupling reactions.

Total synthesis of the azolemycins.

The first total syntheses of newly isolated polyazole natural products azolemycins A-D, along with the synthesis of the tetra-oxazole non-natural analogue, are described.