The Spectrum of Acute Cerebrovascular Disease in Patients with COVID-19.

(1) Background: COVID-19 infection is responsible for the ongoing pandemic and acute cerebrovascular disease (CVD) has been observed in COVID-19 patients. (2) Methods: We conducted a retrospective, observational study of hospitalized adult patients admitted to our hospital with SARS-CoV-2 and acute cerebrovascular disease. All clinical data were reviewed including epidemiology, clinical features, laboratory data, neuroradiological findings, hospital management and course from 32 patients hospitalized for COVID-19 management with acute cerebrovascular disease. (3) Results: Acute CVD with COVID-19 was associated with higher NIH stroke scale on discharge compared to non-COVID-19 CVDs. Seizures complicated the hospital course in 16% of COVID-19 patients with CVD. The majority of the acute CVDs were ischemic (81%) in nature followed by hemorrhagic (22%). Acute CVD with COVID-19 resulted in average hospital stays greater than twice that of the control group (13 days in COVID-19, 5 days in control). Acute CVD with COVID-19 patients had worse clinical outcomes with 31% patient deaths and 6% discharged to hospice. In the control group, 6% of patients died. (4) Conclusions: Acute CVD associated with COVID-19 tends to be more complicated with unique and adverse clinical phenotype, longer hospital admissions, and worse clinical outcomes.

Innovations in Drug Delivery for Chronic Wound Healing.

Wound healing is a varied and complex process designed to restore normal skin structure, function, and appearance in a timely manner. To achieve this goal, different immune and biological systems participate in coordination through four separate steps, including homeostasis, inflammation, proliferation, and regeneration. Each step involves the function of different cells, cytokines, and growth factors. However, chronic ulcers, which are classified into three types of ulcers, namely vascular ulcers, diabetic ulcers, and pressure ulcers, are not able to heal through the mentioned natural stages. This, in turn, causes mental and physical problems for these people and, as a result, imposes high economic and social costs on the society. In this regard, using a system that can accelerate the healing process of such chronic wounds, as an urgent need in society, should be considered. Therefore, in this study, the innovations of drug delivery systems for the healing of chronic wounds using hydrogels, nanomaterials, and membranes are discussed and reviewed.

The Effect of Poly (Ethylene glycol) Emulation on the Degradation of PLA/Starch Composites.

As a hydrophilic renewable polymer, starch has been widely used in biocompatible plastics as a filler for more than two decades. The present study aimed at investigating the effects of polyethylene glycol (PEG), as a plasticizer, on the physicochemical properties of a hybrid composite-polylactic acid (PLA) and thermoplastic starch (TPS). A solvent evaporation process was adopted to gelatinize the starch and disparate PEG contents ranging from 3 to 15 wt.% (with respect to the sample weight) were examined. It was revealed that the increase in the PEG content was accompanied by an increment in the starch gelatinization degree. Referring to the microstructural analyses, the TPS/PLA mixture yielded a ductile hybrid composite with a fine morphology and a uniform phase. Nevertheless, two different solvents, including acetone and ethanol, were used to assess if they had any effect on the hybrid's morphology, tensile strength and thermal properties. It was found that ethanol culminated in a porous hybrid composite with a finer morphology and better starch distribution in the PLA structure than acetone. As the result of PEG addition to the composite, the crystallinity and tensile strength were decreased, whereas the elongation increased. The hydrolytic degradation of samples was assessed under different pH and thermal conditions. Moreover, the microbial degradation of the PLA/TPS hybrid composite containing different PEG molar fractions was investigated in the soil for 45 days. The rate of degradation in both hydrolytic and biodegradation increased in the samples with a higher amount of PEG with ethanol solvent.

Targets and Combs: A Case of Lupus Enteritis.

Lupus is a common autoimmune disorder with the potential to affect all organ systems. Lupus enteritis is a rare complication that is seen in a subset of patients that present with gastrointestinal symptoms. Its diagnosis commonly involves imaging, showing bowel wall edema as the target sign and vascular engorgement of bowel vessels as the comb sign on CT scans. These findings can help guide the diagnosis, but they are nonspecific and are also found in other conditions that cause bowel wall ischemia. These symptoms are reversible if treated with immunosuppressants. Unfortunately, recurrence is common in lupus enteritis and perforation needs to be ruled out on presentation. In this report, we present the case of a patient with known lupus who was diagnosed with lupus enteritis on imaging and was treated with immunosuppressants. The patient's symptoms resolved subsequently. Our case highlights the fact that the appropriate diagnosis and management of this condition require physical exams, labs, and imaging.

Perforated Gangrenous Gallbladder in an Asymptomatic Patient.

Acute cholecystitis or inflammation of the gallbladder is a common cause of hospitalizations. A percentage of those patients will progress to gangrenous cholecystitis and perforation. This medical emergency can lead to peritonitis, which has increased morbidity and mortality. The first-line modality for the diagnosis of acute cholecystitis is an ultrasound, but if it is inconclusive, then a computed tomography (CT) scan may be beneficial. Gangrenous cholecystitis and perforation have been reported in asymptomatic diabetic patients secondary to diabetic neuropathy and/or gallbladder ischemia leading to nerve denervation. Yet, here we present the case of an asymptomatic non-diabetic patient with gangrenous gallbladder perforation that was treated with antibiotics and drain placements. Diagnosis and treatment involve the collaboration between primary care, interventional, and diagnostic services to appropriately manage these patients. This case demonstrates that clinicians should have a low threshold to conduct CT scan of the abdomen, especially when there is a sudden resolution of pain.

Cracking the Case of Achalasia-induced Syncopal Episode.

Achalasia is an uncommon disease that occurs due to inability of lower esophageal sphincter from relaxing, leading to dysphagia to liquids and solids. Clues to this diagnosis include: failed treatment with proton pump inhibitors, and changes on imaging studies including chest X-ray and barium esophagogram. Ultimately it is a diagnosis made on esophageal manometry. Swallow-induced syncope has been known in patients with achalasia for almost three centuries. Here we present the case of a patient with achalasia and a non-swallowing syncopal episode. To our knowledge and extensive search, there has been no report of a similar case.

Weak Knees: A Case of Atorvastatin-induced Dermatomyositis.

HMG-CoA reductase inhibitors (statins) are one of the most widely used medications in the primary care setting, and like any medications they have many side effects. The common ones include myalgias and rare ones include dermatomyositis. Here we present the case of atorvastatin-induced dermatomyositis with an unfortunate progression. This mandates a low threshold for first contact doctors to screen their patients for new-onset muscle weakness and rash after starting a statin recently, like our patient who had started atorvastatin several months before. This case adds to the previously reported cases and provides further evidence for statins being triggers of immune-mediated disease. The appropriate management of this condition requires a collaborative effort involving clinical judgment, laboratory testing, and imaging.

Asymptomatic Hepatic Sequestration with Extreme Hyperbilirubinemia in an Adult Homozygous Sickle Cell Patient.

It has been estimated that there are greater than 100,000 individuals in the US with sickle cell disease. Hepatic sequestration is a known sequelae of sickle cell disease that rarely leads to extreme hyperbilirubinemia (total serum bilirubin greater than 20 mg/dl). Our 26-year-old male patient, though compliant with regular transfusion exchanges, presented with hepatic sequestration, with minimal symptoms and hyperbilirubinemia up to approximately 40 mg/dl. The severity of asymptomatic hepatic sequestration seen in our patient has never been reported in the literature. This mandates a low threshold to screen for sickle cell complications and promptly treating these patients admitted to the hospital with exchange transfusions.

The Effect of Cerebral Palsy Disease Severity, Socioeconomic Status, and Educational Background on Selective Percutaneous Myofascial Lengthening Reoperation Rates.

Cerebral palsy (CP) is a neuro-developmental disorder. Spastic CP is the most common type of CP and is characterized by contractures of the extremities. Selective Percutaneous Myofascial Lengthening (SPML) is a minimally invasive procedure practiced by a handful of physicians in the US, and it decreases contractures and increases the range of motion in individuals with spastic CP. This study wanted to examine if there was an association between CP severity, socioeconomic status, and reoperation rates. This study used electronic medical records (EMR) to include 626 patients with spastic CP who had surgeries between January 2006 and December 2012. The zip codes from the EMR were used to determine the inflation-adjusted mean income and educational qualification (a high school education or higher) of the community via the US Census Bureau. Disease severity before the initial surgery was determined by using the functional mobility scale in the EMR to compute the Gross Motor Function Classification System (GMFCS) level. Then the data was graphed and averages were taken for the reoperation versus the no-reoperation populations, and Student's t-tests were run to determine statistical significance. The data showed that communities with higher education and income tended to reoperate more often. The higher number of reoperations in affluent communities could mean that either more affluent communities are better educated and know the benefits of bringing their children back for reoperation or that they require further education about physical therapy after the initial surgery to decrease the incidence of reoperation. This retrospective study is a level 2 study looking at the socioeconomic and educational backgrounds and disease severity and their association with reoperation rates.

Vascular Complications of Splenectomy in a Patient with Gastric Dieulafoy-like Lesions in Left-sided Portal Hypertension Secondary to Splenic Vein and Artery Thrombosis.

Due to lower clinical significance, the management of Dieulafoy and Dieulafoy-like lesions is less commonly reported than the management of their impending venous equivalent, variceal bleeding. Though Dieulafoy and Dieulafoy-like lesions are often benign, they can become life-threatening in certain clinical scenarios, especially with substantial changes in hemodynamic blood flow, which results in hemorrhage. Post-procedural hemodynamic blood flow should be carefully monitored in patients who receive procedures that drastically alter hemodynamic flow pressures. Factoring in the presence of Dieulafoy and Dieulafoy-like lesions might deepen the complexity of an intuitive surgical or interventional procedure for an experienced operator, and should, therefore, involve the cooperative effort between surgical, interventional, and diagnostic services to appropriately manage the patients. The case we present demonstrates the dire consequences of a routine splenectomy when a considerable change in hemodynamic pressure across benign Dieulafoy-like lesions occurs in a patient with both splenic artery and venous thrombosis.

How preparation and preservation procedures affect the properties of amniotic membrane? How safe are the procedures?

Human amniotic membrane (AM) has been widely used for tissue engineering and regenerative medicine applications. AM has many favorable characteristics such as high biocompatibility, antibacterial activity, anti-scarring property, immunomodulatory effects, anti-cancer behavior and contains several growth factors that make it an excellent natural candidate for wound healing. To date, various methods have been developed to prepare, preserve, cross-link and sterilize the AM. These methods remarkably affect the morphological, physico-chemical and biological properties of AM. Optimization of an effective and safe method for preparation and preservation of AM for a specific application is critical. In this review, the isolation, different methods of preparation, preservation, cross-linking and sterilization as well as their effects on properties of AM are well discussed. For each section, at least one effective and safe protocol is described in detail.

Robust segmentation of arterial walls in intravascular ultrasound images using Dual Path U-Net.

A Fully Convolutional Network (FCN) based deep architecture called Dual Path U-Net (DPU-Net) is proposed for automatic segmentation of the lumen and media-adventitia in IntraVascular UltraSound (IVUS) frames, which is crucial for diagnosis of many cardiovascular diseases and also for facilitating 3D reconstructions of human arteries. One of the most prevalent problems in medical image analysis is the lack of training data. To overcome this limitation, we propose a twofold solution. First, we introduce a deep architecture that is able to learn using a small number of training images and still achieves a high degree of generalization ability. Second, we strengthen the proposed DPU-Net by having a real-time augmentor control the image augmentation process. Our real-time augmentor contains specially-designed operations that simulate three types of IVUS artifacts and integrate them into the training images. We exhaustively assessed our twofold contribution over Balocco's standard publicly available IVUS 20 MHz and 40 MHz B-mode dataset, which contain 109 training image, 326 test images and 19 training images, 59 test images, respectively. Models are trained from scratch with the training images provided and evaluated with two commonly used metrics in the IVUS segmentation literature, namely Jaccard Measure (JM) and Hausdorff Distance (HD). Experimental results show that DPU-Net achieves 0.87 JM, 0.82 mm HD and 0.86 JM, 1.07 mm HD over 40 MHz dataset for segmenting the lumen and the media, respectively. Also, DPU-Net achieves 0.90 JM, 0.25 mm HD and 0.92 JM, 0.30 mm HD over 20 MHz images for segmenting the lumen and the media, respectively. In addition, DPU-Net outperforms existing methods by 8-15% in terms of HD distance. DPU-Net also shows a strong generalization property for predicting images in the test sets that contain a significant amount of major artifacts such as bifurcations, shadows, and side branches that are not common in the training set. Furthermore, DPU-Net runs within 0.03 s to segment each frame with a single modern GPU (Nvidia GTX 1080). The proposed work leverages modern deep learning-based method for segmentation of lumen and the media vessel walls in both 20 MHz and 40 MHz IVUS B-mode images and achieves state-of-the-art results without any manual intervention. The code is available online at https://github.com/Kulbear/IVUS-Ultrasonic.

Segmentation of arterial walls in intravascular ultrasound cross-sectional images using extremal region selection.

Intravascular Ultrasound (IVUS) is an intra-operative imaging modality that facilitates observing and appraising the vessel wall structure of the human coronary arteries. Segmentation of arterial wall boundaries from the IVUS images is not only crucial for quantitative analysis of the vessel walls and plaque characteristics, but is also necessary for generating 3D reconstructed models of the artery. The aim of this study is twofold. Firstly, we investigate the feasibility of using a recently proposed region detector, namely Extremal Region of Extremum Level (EREL) to delineate the luminal and media-adventitia borders in IVUS frames acquired by 20 MHz probes. Secondly, we propose a region selection strategy to label two ERELs as lumen and media based on the stability of their textural information. We extensively evaluated our selection strategy on the test set of a standard publicly available dataset containing 326 IVUS B-mode images. We showed that in the best case, the average Hausdorff Distances (HD) between the extracted ERELs and the actual lumen and media were 0.22  mm and 0.45 mm, respectively. The results of our experiments revealed that our selection strategy was able to segment the lumen with ⩽0.3 mm HD to the gold standard even though the images contained major artifacts such as bifurcations, shadows, and side branches. Moreover, when there was no artifact, our proposed method was able to delineate media-adventitia boundaries with 0.31 mm HD to the gold standard. Furthermore, our proposed segmentation method runs in time that is linear in the number of pixels in each frame. Based on the results of this work, by using a 20 MHz IVUS probe with controlled pullback, not only can we now analyze the internal structure of human arteries more accurately, but also segment each frame during the pullback procedure because of the low run time of our proposed segmentation method.

Extremal Regions Detection Guided by Maxima of Gradient Magnitude.

A problem of computer vision applications is to detect regions of interest under different imaging conditions. The state-of-the-art maximally stable extremal regions (MSERs) detects affine covariant regions by applying all possible thresholds on the input image, and through three main steps including: (1) making a component tree of extremal regions' evolution; (2) obtaining region stability criterion; and (3) cleaning up. The MSER performs very well, but, it does not consider any information about the boundaries of the regions, which are important for detecting repeatable extremal regions. We have shown in this paper that employing prior information about boundaries of regions results in a novel region detector algorithm that not only outperforms MSER, but avoids the MSER's rather complicated steps of enumeration and the cleaning up. To employ the information about the region boundaries, we introduce maxima of gradient magnitudes (MGMs) which are shown to be points that are mostly around the boundaries of the regions. Having found the MGMs, the method obtains a global criterion for each level of the input image which is used to find extremum levels (ELs). The found ELs are then used to detect extremal regions. The proposed algorithm which is called extremal regions of extremum levels (EREL) has been tested on the public benchmark data set of Mikolajczyk. The obtained experimental results show that the inclusion of region boundaries through MGMs, results in a detector that detects regions with high repeatability scores and is more robust against noise compared with MSER.