Examination Under Anesthesia Improves Agreement on Mechanical Stability: A Survey of Experienced Pelvic Surgeons.

OBJECTIVES: To assess agreement among experts in pelvic fracture management regarding stability and need for operative repair of lateral compression-type pelvic fractures with static radiographs compared to static radiographs and examination under anesthesia (EUA). SETTING: Online survey. PATIENTS/PARTICIPANTS: Ten patients who presented to our level-1 trauma center with a pelvic ring injury were selected. Vignettes were distributed to 11 experienced pelvic surgeons. INTERVENTION: Examination under anesthesia. MAIN OUTCOME MEASUREMENTS: Agreement regarding pelvic fracture stability and need for surgical fixation. RESULTS: Agreement on stability was achieved in 4 (40%) cases without EUA compared to 8 (80%) cases with EUA. Interreviewer reliability was poor without EUA and moderate with EUA (0.207 vs. 0.592). Agreement on need to perform surgery was achieved in 5 (50%) cases compared to 6 (60%) cases with EUA. Interreviewer reliability was poor without EUA and moderate with EUA (0.250 vs. 0.432). For reference cases with agreement, surgeons were able to predict stability or instability using standard imaging in 57 of a possible 88 reviewer choices (64.8%) compared to 82 of 88 choices (93.2%) with the addition of EUA (P < 0.0001). CONCLUSIONS: EUA increased agreement among experienced pelvic surgeons regarding the assessment of pelvic ring stability and the need for operative intervention. Further research is necessary to define specific indications for which patients may benefit from EUA.

Modeling transmission dynamics of lyme disease: Multiple vectors, seasonality, and vector mobility.

Lyme disease is the most prevalent tick-borne disease in the United States, which humans acquire from an infected tick of the genus Ixodes (primarily Ixodes scapularis). While previous studies have provided useful insights into various aspects of Lyme disease, the tick's host preference in the presence of multiple hosts has not been considered in the existing models. In this study, we develop a transmission dynamics model that includes the interactions between the primary vectors involved: blacklegged ticks (I. scapularis), white-footed mice (Peromyscus leucopus), and white-tailed deer (Odocoileus virginianus). Our model shows that the presence of multiple vectors may have a significant impact on the dynamics and spread of Lyme disease. Based on our model, we also calculate the basic reproduction number, R 0 , a threshold value that predicts whether a disease exists or dies out. Subsequent extensions of the model consider seasonality of the tick's feeding period and mobility of deer between counties. Our results suggest that a longer tick peak feeding period results in a higher infection prevalence. Moreover, while the deer mobility may not be a primary factor for short-term emergence of Lyme disease epidemics, in the long-run it can significantly contribute to local infectiousness in neighboring counties, which eventually reach the endemic steady state.

Intracranial Atherosclerosis Versus Primary Angiitis of the Central Nervous System: a Case Report.

Primary angiitis of the central nervous system (PACNS) is a rare disease with various clinical presentations. It is the preferred name for vasculitis that is confined to the central nervous system (CNS) and is often considered a diagnosis of exclusion in vascular or inflammatory CNS diseases. This case describes a 46-year-old right-handed female with a past medical history of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus type two (DM2), obesity, and hemorrhagic stroke who was transferred from an outside facility after a one-month hospitalization to be evaluated for CNS vasculitis. Emergency medical personnel who brought the patient to the receiving hospital endorsed dysarthria and fluctuating level of cognition. Before she was transferred, the patient underwent a series of computed tomography (CT) and magnetic resonance imaging and angiographies (MRI/MRA) as well as four-vessel angiography. The studies revealed multiple bilateral striatal and cortical infarcts, scattered narrowing and occlusion of major cerebral vasculature, as well as other signs initially more suggestive of intracranial atherosclerosis than CNS vasculitis. Before she was transferred, imaging demonstrated a new cortical stroke. Hypercoagulable studies were positive for protein C deficiency although ensuing echocardiograms with normal ejection fractions were negative for a source of cardioembolism. Having undergone extensive rheumatological, radiological, and neurosurgical evaluation in the receiving facility, recommendations were made for the patient to undergo leptomeningeal biopsy to confirm the diagnosis of vasculopathy and to specifically rule out intracranial atherosclerosis and reversible cerebral vasoconstriction syndrome (RCVS).

Fas ligand is responsible for CXCR3 chemokine induction in CD4+ T cell-dependent liver damage.

Immune-mediated hepatic damage has been demonstrated in the pathogenesis of hepatitis C virus (HCV) and other hepatotrophic infections. Fas/Fas ligand (FasL) interaction plays a critical role in immune-mediated hepatic damage. To understand the molecular mechanism(s) of FasL-mediated liver inflammation, we examined the effect of CD4(+) T cells expressing high levels of FasL on the initiation of hepatic damage through analysis of chemokine and chemokine receptor expression in HCV core x TCR (DO11.10) double-transgenic mice. In vivo antigenic stimulation triggers a marked influx of core-expressing Ag-specific CD4(+) T cells into the liver of the immunized core(+) TCR mice but not their core(-) TCR littermates. Strikingly, the inflammatory process in the liver of core(+) TCR mice was accompanied by a dramatic increase in IFN-inducible protein 10 and monokine induced by IFN-gamma production. The intrahepatic lymphocytes were primarily CXCR3-positive and anti-CXCR3 Ab treatment abrogates migration of CXCR3(+) lymphocytes into the liver and hepatic damage. Importantly, the blockade of Fas/FasL interaction reduces the expression of IFN-inducible protein 10 and monokine induced by IFN-gamma and cellular infiltration into the liver. These findings suggest that activated CD4(+) T cells with elevated FasL expression are involved in promoting liver inflammation and hepatic damage through the induction of chemokines.