Utilizing 3D printing to assist pre-procedure planning of transjugular intrahepatic portosystemic shunt (TIPS) procedures: a pilot study.

BACKGROUND: 3D (three-dimensional) printing has been adopted by the medical community in several ways, procedure planning being one example. This application of technology has been adopted by several subspecialties including interventional radiology, however the planning of transjugular intrahepatic portosystemic shunt (TIPS) placement has not yet been described. The impact of a 3D printed model on procedural measures such as procedure time, radiation exposure, intravascular contrast dosage, fluoroscopy time, and provider confidence has also not been reported. METHODS: This pilot study utilized a quasi-experimental design including patients who underwent TIPS. For the control group, retrospective data was collected on patients who received a TIPS prior to Oct 1, 2020. For the experimental group, patient-specific 3D printed models were integrated in the care of patients that received TIPS between Oct 1, 2020 and April 15, 2021. Data was collected on patient demographics and procedural measures. The interventionalists were surveyed on their confidence level and model usage following each procedure in the experimental group. RESULTS: 3D printed models were created for six TIPS. Procedure time (p = 0.93), fluoroscopy time (p = 0.26), and intravascular contrast dosage (p = 0.75) did not have significant difference between groups. Mean radiation exposure was 808.8 mGy in the group with a model compared to 1731.7 mGy without, however this was also not statistically significant (p = 0.09). Out of 11 survey responses from interventionists, 10 reported "increased" or "significantly increased" confidence after reviewing the 3D printed model and all responded that the models were a valuable tool for trainees. CONCLUSIONS: 3D printed models of patient anatomy can consistently be made using consumer-level, desktop 3D printing technology. This study was not adequately powered to measure the impact that including 3D printed models in the planning of TIPS procedures may have on procedural measures. The majority of interventionists reported that patient-specific models were valuable tools for teaching trainees and that confidence levels increased as a result of model inclusion in procedure planning.

Feline Ovarian Pedicle Ligation: A Comparison of Two Techniques Taught among AAVMC Institutions.

Ligation of the feline ovarian pedicle during ovariohysterectomy is achieved, principally, via one of the following methods: double ligation of the ovarian pedicle or autoligation of the ovarian pedicle, also known as the pedicle tie. The objective of this study was to assess and quantify two methods of teaching feline ovariohysterectomies, specifically ligation of the ovarian pedicle, at American Association of Veterinary Medical Colleges-accredited veterinary schools. Surveys were sent to 52 AAVMC member schools, with an overall response rate of 67.3%. Of the 35 schools that responded to the survey, 34 (97.1%) reported that they teach double ligation of the feline ovarian pedicle, whereas 17 (48.6%) of respondents reported teaching autoligation of the feline ovarian pedicle (2 respondents indicated that a single ligature is sufficient). Only 1 of the schools that reported teaching pedicle ties indicated that it did not teach double ligation of the ovarian pedicle; 16 of the 35 schools that responded to the survey (45.7%) reported teaching both techniques. The results indicate that significantly fewer institutions are currently teaching autoligation of the feline ovarian pedicle than those teaching double ligation of the feline ovarian pedicle.

Exceptional response to Erlotinib monotherapy in EGFR Exon 19-deleted, KRAS wild-type, Chemo-refractory advanced pancreatic adenocarcinoma.

Advanced pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive tumor with an abysmal prognosis. Beyond the first-line setting, treatment for advanced PDAC is limited and suboptimal. Also, the efficacy of epidermal growth factor receptor (EGFR) targeted therapy alone in the chemo-refractory setting in PDAC tumors harboring druggable EGFR mutations is unclear. Here we describe the case of a patient with chemo-refractory advanced PDAC with an activating exon-19 EGFR mutation who had an exceptional response to erlotinib monotherapy.

Subhypnotic dose of intravenous propofol stimulates appetite in cats with stress-induced anorexia.

BACKGROUND: Stress-induced anorexia is common in cats. While medications are available to stimulate appetite, many require oral administration, have delayed onset-of-action or cause adverse side effects. The aim of this study was to determine whether cats diagnosed with stress-induced anorexia given a subhypnotic dose of intravenous propofol would have increased short-term appetite as compared to those given placebo. METHODS: Anorexic shelter cats received either 1 mg/kg propofol or 1 mL saline placebo and then presented with various commercial cat foods. Grams of food consumed was measured at 15 and 30 min, and total grams compared between treatment and control groups using the Wilcoxon rank-sum test. 12 cats were enrolled, with six cats randomly assigned to each group. RESULTS: The median amount consumed by the treatment group was 31 g (range: 0-72), with the median for the four cats (67 per cent) who consumed food being 45 g (range: 26-72), or 49 per cent of their daily maintenance calorie requirement. The median amount consumed by control cats was 0 g (range: 0-5), with one cat consuming food. Total grams consumed was different between treatment and control groups (P=0.05). CONCLUSION: A subhypnotic dose of intravenous propofol increased appetite in cats with stress-induced anorexia for a 30 min period.

Health Needs Assessment of Five Pennsylvania Plain Populations.

We performed a health needs assessment for five Plain communities in Pennsylvania from a random sample of households, comparing them to the general population of Pennsylvania adults. Plain respondents were more likely to drink well water, as likely to eat fruit and vegetables and much more likely to drink raw milk and be exposed to agricultural chemicals. Plain respondents were less likely to receive screening exams compared to the general population and there was variation from settlement to settlement in whether respondents had a regular doctor, whether they received preventive screenings or had their children vaccinated, with Mifflin County Amish generally lowest in these and Plain Mennonites highest. Plain respondents reported good physical and mental health compared to the general population but Groffdale Mennonite respondents had a high proportion of diagnoses of depression and were more likely to be receiving treatment for a mental health condition. Most Plain respondents would want a spouse tested for genetic disease with Mifflin County Amish least in favor of these tests. Despite their geographic and genetic isolation, the health of Plain communities in Pennsylvania is similar to that of other adults in the state.

Evaluation of sutureless scrotal castration for pediatric and juvenile dogs.

OBJECTIVE To determine complication rates associated with sutureless scrotal castration (SLSC) performed in a large number of pediatric and juvenile dogs and investigate whether procedure duration differed from that of traditional prescrotal castration (TPSC). DESIGN Prospective case series and clinical trial. ANIMALS 400 shelter-owned dogs that underwent SLSC and 18 shelter-owned dogs that underwent TPSC between 2 and 5 months of age. PROCEDURES In the first phase of the study, SLSC was performed for 400 dogs, which were monitored for ≥ 24 hours after surgery to identify surgery-related complications such as hemorrhage, signs of pain, self-trauma, swelling, and dermatitis at the incision site. In the second phase, the durations of 18 SLSC and 18 TPSC procedures were measured and compared. RESULTS No hemorrhage-related complications were identified in any dog during SLSC in the first phase. Complications were all minor and self-limiting and included peri-incisional dermatitis (9/400 [2.3%]), skin bruising (4/400 [1.0%]), and swelling (1/400 [0.3%]). No self-trauma was observed for any dog, nor did any dog require additional analgesic treatment after surgery. Procedure duration was significantly briefer for SLSC (mean ± SD, 1.0 ± 0.2 minutes) than for TPSC (3.5 ± 0.4 minutes). CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that SLSC as evaluated was safe and significantly faster than TPSC when performed in healthy 2- to 5-month-old dogs. The SLSC technique has the potential to improve morbidity and mortality rates as well as financial costs associated with castration, particularly in high-quality, high-volume spay and neuter programs.

Reducing radiation exposure with iterative reconstruction: an inter- and intra-scanner analysis.

Our purpose in this study was to compare delivered radiation exposure via computed tomography dose index volume (CTDIvol) and dose length production (DLP) measurements from computed tomography (CT) examinations performed on scanners with and without image-quality enhancing iterative reconstruction (IR) software. A retrospective analysis was conducted on randomly selected chest, abdomen, and/or pelvis CT examinations from three different scanners from 1 January 2013 to 31 December 2013. CTDIvol and DLP measurements were obtained from two CT scanners with and one CT scanner without IR software. To evaluate inter-scanner variability, we compared measurements from the same model CT scanners, one with and one without IR software. To evaluate intra-scanner variability, we compared measurements between two scanners with IR software from different manufacturers. CT scanners with IR software aided in the overall reduction in radiation exposure, measured as CTDIvol by 30% and DLP by 39% when compared to a scanner without IR. There was no significant difference in CTDlvol or DLP measurements across different manufacturers with IR software. As a result, IR software significantly decreased the radiation exposure to patients, but there were no differences in radiation measurements across CT manufacturers with IR software.

Health Needs Assessment of Plain Populations in Lancaster County, Pennsylvania.

We performed a health needs assessment for three Plain communities in Lancaster County, Pennsylvania from a random sample of households. Compared with the general population of adults, Plain respondents were more likely to be married, to have children, and they had large families; they were more likely to drink well water, to eat fruit and vegetables, to drink raw milk, and to live on a farm. Plain respondents had better physical and mental health and were less likely to have been diagnosed with various medical conditions compared with the general population of adults in Lancaster County but Old Order Mennonite respondents were more likely to have been diagnosed compared with Old Order Amish respondents. Plain respondents usually have a regular doctor and often receive preventive care but Old Order Mennonite respondents were more likely to have a regular doctor, to receive preventive care, to have had their children vaccinated, and to receive routine dental care compared with Old Order Amish respondents. Despite their relative geographic and genetic isolation, and despite the small, relative differences noted, the health of Plain communities in Lancaster County is similar to that of other adults in the County.

Pedicle ties provide a rapid and safe method for feline ovariohysterectomy.

OBJECTIVES: The specific objectives of the present study were to evaluate the rate of hemorrhage-related complications across a large number of feline pedicle tie (PT) procedures, and evaluate for a difference in surgical time between traditional pedicle double ligation (PDL) and PT procedures. METHODS: In the initial phase of the study, 2136 intact female cats underwent an ovariohysterectomy using the PT technique. Hemorrhagic complications not detected intraoperatively were to be confirmed via exploratory surgery or necropsy. The second phase of the study recorded the duration of surgery for four groups: kittens undergoing PTs (n = 50), kittens undergoing PDL (n = 49), adult cats undergoing PTs (n = 50) and adult cats undergoing PDL (n = 54). Kittens were defined as a cat 4 months old or younger. Statistical comparisons of age, body weight and surgical times between the PT and PDL groups were performed within, but not between, kitten and adult cat categories. RESULTS: Six of 2136 (0.281%) cats experienced a hemorrhage-related complication associated with the ovarian pedicle. Five of the six ovarian pedicle hemorrhage-related complications were recognized and corrected intraoperatively, with the remaining hemorrhagic event being detected postoperatively. Surgical times were significantly shorter in PT kittens compared with PDL kittens (4.7 ± 0.1 mins vs 6.7 ± 0.1 mins) and PT adult cats compared with PDL adult cats (5.0 ± 0.2 mins vs 7.0 ± 0.2 mins). CONCLUSIONS AND RELEVANCE: This study demonstrates that the PT technique is associated with a very low risk of hemorrhage-related complications and is significantly faster than double ligating the ovarian pedicle in kittens and adult cats. Use of the PT technique has the potential to be of significant economic benefit in institutions performing large numbers of feline ovariohysterectomies.

Health status, health conditions, and health behaviors among Amish women. Results from the Central Pennsylvania Women's Health Study (CePAWHS).

We performed one of the first systematic, population-based surveys of women in Amish culture. We used these data to examine health status and health risks in a representative sample of 288 Amish women ages 18-45 living in Lancaster County, Pennsylvania, in particular for risks associated with preterm and low birthweight infants, compared with a general population sample of 2,002 women in Central Pennsylvania. Compared with women in the general population, Amish women rated their physical health approximately at the same level, but reported less stress, fewer symptoms of depression, and had higher aggregate scores for mental health. Amish women reported low levels of intimate partner violence, high levels of social support, and they perceived low levels of unfair treatment owing to gender compared with the general population. Amish women also reported higher fertility, fewer low birthweight babies, but the same number of preterm births as the general population. The findings suggest that these outcomes may be due to higher levels of social support and better preconceptional behavior among Amish women.

Increases in CD4+ T lymphocytes occur without increases in thymic size in HIV-infected subjects receiving interleukin-2 therapy.

OBJECTIVE: To examine the potential contribution of the thymus to CD4+ T-lymphocyte increases in HIV-infected patients receiving intermittent interleukin-2 (IL-2) therapy. DESIGN: Fifteen HIV-infected patients treated with antiretroviral regimens who were enrolled in a study of intermittent IL-2 therapy and were willing to undergo serial thymic computed tomography (CT) were prospectively studied. METHODS: Thymic CT was performed before and approximately 6 and 12-17 months after intermittent IL-2 therapy was started. Scans were graded in a blinded manner. Changes in lymphocyte subpopulations were determined by flow cytometry. RESULTS: Statistically significant increases in CD4+ T lymphocytes occurred with IL-2 administration, with a preferential increase in naive relative to memory CD4+ T cells. Despite this increase in naive CD4+ T cells, overall there was a modest decrease in thymic volume observed during the study period. No correlation was found between changes in thymic volume indices and total, naive, or memory CD4+ T-lymphocyte counts. CONCLUSIONS: These findings demonstrate that the profound CD4+ T-lymphocyte increases seen with intermittent IL-2 administration are not associated with increases in thymic volume and more likely are due to peripheral expansion rather than increased thymic output.

High prevalence of osteonecrosis of the femoral head in HIV-infected adults.

BACKGROUND: Osteonecrosis has been reported to occur occasionally among HIV-infected patients. The diagnosis of symptomatic osteonecrosis of the hip in two of the authors' patients, together with reports from community physicians, raised a concern that the prevalence of osteonecrosis is increasing. OBJECTIVE: To determine the prevalence of osteonecrosis of the hip in asymptomatic HIV-infected patients and to identify potential risk factors associated with osteonecrosis. DESIGN: Survey and comparison study. SETTING: The Clinical Center of the U.S. National Institutes of Health. PARTICIPANTS: 339 asymptomatic HIV-infected adults (of 364 asked to participate) and 118 age- and sex-matched HIV-negative volunteers enrolled between 1 June and 15 December 1999. MEASUREMENTS: Osteonecrosis of the hip, as documented by magnetic resonance imaging. Data from clinic records and a patient questionnaire administered before magnetic resonance imaging were used in an analysis of risk factors. A subset of patients was evaluated for hypercoagulable state. RESULTS: Fifteen (4.4% [95% CI, 2.5% to 7.2%]) of 339 HIV-infected participants had osteonecrosis lesions on magnetic resonance imaging, and no HIV-negative participants had similar lesions. Among HIV-infected participants, osteonecrosis occurred more frequently in those who used systemic corticosteroids, lipid-lowering agents, or testosterone; those who exercised routinely by bodybuilding; and those who had detectable levels of anticardiolipin antibodies. CONCLUSIONS: Patients infected with HIV have an unexpectedly high occurrence of osteonecrosis of the hip. Although screening asymptomatic patients is not warranted, HIV-infected patients with persistent groin or hip pain should be evaluated for this debilitating complication.

Urinary cytology associated with human polyomavirus and indinavir therapy in HIV-infected patients.

We retrospectively analyzed 155 urine cytology samples (78 from patients treated with indinavir; 77, no indinavir) from 90 HIV+ patients to evaluate possible association between human polyomavirus and hematuria and to describe indinavir-associated urinary cytologic findings. The CD4 count also was recorded. Variables studied included the presence of cellular viral changes consistent with polyomavirus infection (PVCs), microscopic hematuria, multinucleated cells, indinavir crystals, neutrophils, and eosinophils. Twenty-two samples (15.8%) from patients with CD4 counts of more than 200/microL (>200 x 10(6)/L) showed PVCs. Multinucleated cells, of presumed histiocytic origin based on morphologic features and selective immunocytochemical findings, were present in a higher percentage of samples from indinavir-treated patients. Neutrophils were present in a higher percentage of indinavir-treated patients. Indinavir crystals were identified in 9 samples (12%) from patients receiving indinavir The lower percentage of PVCs in HIV+ patients with high CD4 counts likely represents an indirect antipolyomavirus indinavir effect by boosting immunity. Multinucleated cells (presumably histiocytic) and acute inflammation are associated with indinavir therapy. Indinavir crystals have a characteristic fan or circular lamellate appearance. Because indinavir crystals may be associated with genitourinary disease, recognizing and reporting them is clinically relevant in HIV+ patients.

Indinavir-associated interstitial nephritis and urothelial inflammation: clinical and cytologic findings.

The objective of the present study was to characterize the genitourinary syndromes that accompany indinavir-associated pyuria. Of 23 indinavir-treated patients with persistent pyuria, 4 had isolated interstitial nephritis, 10 had both interstitial nephritis and urothelial inflammation, 7 had isolated urothelial inflammation, and 2 had pyuria with nonspecific urinary tract inflammation. A total of 21 patients had multinucleated histiocytes identified by cytologic testing of urine specimens. Urine abnormalities resolved in all 20 patients who stopped receiving indinavir therapy. Pyuria continued in the 3 patients who continued receiving indinavir. Six patients had elevated serum creatinine levels, which returned to baseline levels when indinavir was discontinued. In conclusion, indinavir-associated pyuria was frequently associated with evidence of interstitial nephritis and/or urothelial inflammation, multinucleated histiocytes were commonly present in urine specimens, and cessation of indinavir therapy was associated with prompt resolution of urine abnormalities.

Diagnosis of avascular necrosis of the hip in asymptomatic HIV-infected patients: Clinical correlation of physical examination with magnetic resonance imaging.

OBJECTIVE: To determine if physical examination can identify avascular necrosis of the hip (AVN) in asymptomatic HIV-infected patients. DESIGN: Prospective, blinded population studyResults: Ten of the 176 patients were positive for AVN by MRI. Four subjects had unilateral disease and six had bilateral disease. Five hips (1.4%) in four patients were indeterminate. We evaluated physical examination maneuvers both singly and in combination. Tests done singly generally provided a higher degree of specificity (67-92%) but sensitivities were lower (0-50%) with all p-values ≥0.08. Positive predictive values based on physical exam, were <17% and negative predictive values were >90% for any single test. Combining all tests gave a high sensitivity (88%) and negative predictive value (98%), but low specificity (34%) and positive predictive value (6%) with p = 0.10. Only two of 16 hips with positive MRI findings showed no abnormalities when all tests were combinedConclusions: This study establishes the limited usefulness of a detailed physical examination of the hip early in the course of AVN. Patients who test negative on physical exam are unlikely to have AVN positive by MRI. Positive findings on physical examination of the hip may help identify patients who need further evaluation by MRI based on overall clinical suspicion.

Acute hepatitis caused by a novel strain of hepatitis E virus most closely related to United States strains.

A unique hepatitis E virus (HEV) strain was identified as the aetiological agent of acute hepatitis in a United States (US) patient who had recently returned from vacation in Thailand, a country in which HEV is endemic. Sequence comparison showed that this HEV strain was most similar, but not identical, to the swine and human HEV strains recovered in the US. Phylogenetic analysis revealed that this new HEV isolate was closer to genotype 3 strains than to the genotype 1 strains common in Asia. The fact that this HEV was closely related to strains recovered in countries where HEV is not endemic and was highly divergent from Asian HEV strains raises the questions of where the patient's infection was acquired and of whether strains are geographically as localized as once thought.

Environmentally induced variation in body size of turtles hatching in natural nests.

Eggs from three snapping turtles (Chelydra serpentina) were divided between two natural nests in a factorial experiment assessing the role of the nest environment as a cause for variation in body size and energy reserves of hatchlings at our study site in northcentral Nebraska. Nest # 1 was located in an unshaded area on the south side of a high sandhill, whereas nest #2 was located in an unshaded area on level ground. Eggs in nest #1 increased in mass over the course of incubation, with eggs at the bottom of the nest gaining more mass than eggs nearer to the surface. In constrast, eggs in nest #2 lost mass during incubation, with eggs at the bottom declining less in mass than eggs at the top of the cavity. Hatchlings from nest #1 were much larger (but contained smaller masses of unused yolk) than hatchlings from nest #2. Additionally, eggs from the lower layers in both nests tended to produce larger hatchings (but with smaller masses of unused yolk) than eggs from the upper layers. Thus, ecologically important variation in body size and nutrient reserves of hatchling snapping turtles results from variation in the environment among and within nests.