Ensemble learning for fetal ultrasound and maternal-fetal data to predict mode of delivery after labor induction.

Providing adequate counseling on mode of delivery after induction of labor (IOL) is of utmost importance. Various AI algorithms have been developed for this purpose, but rely on maternal-fetal data, not including ultrasound (US) imaging. We used retrospectively collected clinical data from 808 subjects submitted to IOL, totaling 2024 US images, to train AI models to predict vaginal delivery (VD) and cesarean section (CS) outcomes after IOL. The best overall model used only clinical data (F1-score: 0.736; positive predictive value (PPV): 0.734). The imaging models employed fetal head, abdomen and femur US images, showing limited discriminative results. The best model used femur images (F1-score: 0.594; PPV: 0.580). Consequently, we constructed ensemble models to test whether US imaging could enhance the clinical data model. The best ensemble model included clinical data and US femur images (F1-score: 0.689; PPV: 0.693), presenting a false positive and false negative interesting trade-off. The model accurately predicted CS on 4 additional cases, despite misclassifying 20 additional VD, resulting in a 6.0% decrease in average accuracy compared to the clinical data model. Hence, integrating US imaging into the latter model can be a new development in assisting mode of delivery counseling.

Relationship between bite force, occlusal contact area, and three-dimensional facial soft tissue in dentofacial deformities.

PURPOSE: This study aimed to investigate three-dimensional facial soft tissue dimensions, maximum bite force (MBF), and occlusal contact area in patients with DFD. In addition, we analyzed the relationship between MBF and the three-dimensional facial measurements. METHODS: Thirty-two patients with skeletal Class III DFD and 20 patients with Class II DFD underwent a soft tissue evaluation using surface laser scanning, as well as MBF and occlusal contact area assessments. The DFD groups were compared with each other and with 25 healthy subjects. RESULTS: Significant morphological differences were found in the transversal, vertical, and anteroposterior dimensions between Class II DFD and Class III DFD. Both DFD groups presented an increased linear distance of chin height, which was strongly related with decreased MBF magnitude. The DFD groups exhibited lower MBF and occlusal contact area, with no significant differences between Class II and Class III DFD. CONCLUSION: The presence of DFD affected 3D measurements of facial soft tissue, causing variations beyond normal limits, lower MBF, and occlusal contact area in both Class II and Class III DFD patients. The vertical dimension might have influenced the lower MBF magnitude in the studied skeletal deformities.

Neuroendocrine breast carcinoma.

Neuroendocrine breast cancer (NEBC) is a rare and heterogeneous entity. It most commonly presents a luminal phenotype and a worse prognosis. When diagnosed in an advanced stage, metastasis from another neuroendocrine tumor should be excluded. This case features a premenopausal woman with an oligometastatic breast large cell neuroendocrine carcinoma, estrogen receptor (ER) positive, and human epidermal growth factor receptor 2 (HER2) negative. Since the patient was very symptomatic at the presentation of the disease, chemotherapy was started. Complete radiological response of the metastatic disease was achieved, and the patient was then submitted to radical breast surgery and bilateral oophorectomy. She subsequently underwent radiation therapy. Since then and to date, she has been under endocrine therapy (ET) and a CDK4/6 inhibitor (CDK4/6i), with no evidence of malignant disease. Evidence to guide the choice of treatment for these tumors is currently scarce. In cases with oligometastatic disease, radical treatment should be considered. Given that this entity is rare, its reporting should be encouraged.

Non-pharmacological interventions to improve sleep quality and quantity for hospitalized adult patients-co-produced study with surgical patient partners: systematic review.

BACKGROUND: Hospitalized patients experience sleep disruption with consequential physiological and psychological effects. Surgical patients are particularly at risk due to surgical stress and postoperative pain. This systematic review aimed to identify non-pharmacological interventions for improving sleep and exploring their effects on sleep-related and clinical outcomes. METHODS: A systematic literature search was performed in accordance with PRISMA guidelines and was preregistered on the Open Science Framework (doi: 10.17605/OSF.IO/EA6BN) and last updated in November 2023. Studies that evaluated non-pharmacological interventions for hospitalized, adult patients were included. Thematic content analysis was performed to identify hypothesized mechanisms of action and modes of administration, in collaboration with a patient partner. Risk of bias assessment was performed using the Cochrane Risk Of Bias (ROB) or Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tools. RESULTS: A total of 59 eligible studies and data from 14 035 patients were included; 28 (47.5%) were randomized trials and 26 included surgical patients (10 trials). Thirteen unique non-pharmacological interventions were identified, 17 sleep measures and 7 linked health-related outcomes. Thematic analysis revealed two major themes for improving sleep in hospital inpatients: enhancing the sleep environment and utilizing relaxation and mindfulness techniques. Two methods of administration, self-administered and carer-administered, were identified. Environmental interventions, such as physical aids, and relaxation interventions, including aromatherapy, showed benefits to sleep measures. There was a lack of standardized sleep measurement and an overall moderate to high risk of bias across all studies. CONCLUSIONS: This systematic review has identified several sleep interventions that are likely to benefit adult surgical patients, but there remains a lack of high-quality evidence to support their routine implementation.

Determinants of HIV late presentation among men who have sex with men in Portugal (2014-2019): who's being left behind?

Introduction: HIV late presentation (LP) remains excessive in Europe. We aimed to analyze the factors associated with late presentation in the MSM population newly diagnosed with HIV in Portugal between 2014 and 2019. Methods: We included 391 newly HIV-1 diagnosed Men who have Sex with Men (MSM), from the BESTHOPE project, in 17 countrywide Portuguese hospitals. The data included clinical and socio-behavioral questionnaires and the viral genomic sequence obtained in the drug resistance test before starting antiretrovirals (ARVs). HIV-1 subtypes and epidemiological surveillance mutations were determined using different bioinformatics tools. Logistic regression was used to estimate the association between predictor variables and late presentation (LP). Results: The median age was 31 years, 51% had a current income between 501-1,000 euros, 28% were migrants. 21% had never been tested for HIV before diagnosis, with 42.3% of MSM presenting LP. 60% were infected with subtype B strains. In the multivariate regression, increased age at diagnosis, higher income, lower frequency of screening, STI ever diagnosed and higher viral load were associated with LP. Conclusion: Our study suggests that specific subgroups of the MSM population, such older MSM, with higher income and lower HIV testing frequency, are not being targeted by community and clinical screening services. Overall, targeted public health measures should be strengthened toward these subgroups, through strengthened primary care testing, expanded access to PrEP, information and promotion of HIV self-testing and more inclusive and accessible health services.

What's new about the tumor microenvironment of urothelial carcinoma?

Urothelial carcinoma is a significant global health concern that accounts for a substantial part of cancer diagnoses and deaths worldwide. The tumor microenvironment is a complex ecosystem composed of stromal cells, soluble factors, and altered extracellular matrix, that mutually interact in a highly immunomodulated environment, with a prominent role in tumor development, progression, and treatment resistance. This article reviews the current state of knowledge of the different cell populations that compose the tumor microenvironment of urothelial carcinoma, its main functions, and distinct interactions with other cellular and non-cellular components, molecular alterations and aberrant signaling pathways already identified. It also focuses on the clinical implications of these findings, and its potential to translate into improved quality of life and overall survival. Determining new targets or defining prognostic signatures for urothelial carcinoma is an ongoing challenge that could be accelerated through a deeper understanding of the tumor microenvironment.

Neuroendocrine breast carcinoma

ABSTRACT Neuroendocrine breast cancer (NEBC) is a rare and heterogeneous entity. It most commonly presents a luminal phenotype and a worse prognosis. When diagnosed in an advanced stage, metastasis from another neuroendocrine tumor should be excluded. This case features a premenopausal woman with an oligometastatic breast large cell neuroendocrine carcinoma, estrogen receptor (ER) positive, and human epidermal growth factor receptor 2 (HER2) negative. Since the patient was very symptomatic at the presentation of the disease, chemotherapy was started. Complete radiological response of the metastatic disease was achieved, and the patient was then submitted to radical breast surgery and bilateral oophorectomy. She subsequently underwent radiation therapy. Since then and to date, she has been under endocrine therapy (ET) and a CDK4/6 inhibitor (CDK4/6i), with no evidence of malignant disease. Evidence to guide the choice of treatment for these tumors is currently scarce. In cases with oligometastatic disease, radical treatment should be considered. Given that this entity is rare, its reporting should be encouraged.

Relationship between bite force, occlusal contact area, and three-dimensional facial soft tissue in dentofacial deformities

ABSTRACT Purpose This study aimed to investigate three-dimensional facial soft tissue dimensions, maximum bite force (MBF), and occlusal contact area in patients with DFD. In addition, we analyzed the relationship between MBF and the three-dimensional facial measurements. Methods Thirty-two patients with skeletal Class III DFD and 20 patients with Class II DFD underwent a soft tissue evaluation using surface laser scanning, as well as MBF and occlusal contact area assessments. The DFD groups were compared with each other and with 25 healthy subjects. Results Significant morphological differences were found in the transversal, vertical, and anteroposterior dimensions between Class II DFD and Class III DFD. Both DFD groups presented an increased linear distance of chin height, which was strongly related with decreased MBF magnitude. The DFD groups exhibited lower MBF and occlusal contact area, with no significant differences between Class II and Class III DFD. Conclusion The presence of DFD affected 3D measurements of facial soft tissue, causing variations beyond normal limits, lower MBF, and occlusal contact area in both Class II and Class III DFD patients. The vertical dimension might have influenced the lower MBF magnitude in the studied skeletal deformities.

A giant cause of recurrent fever

A 73-year-old male patient presented to the Emergency Department with history of weight loss, dysphagia, and recurrent fever. The initial chest radiograph showed a mediastinal hypotransparency and to the complaints of dysphagia the patient did a barium swallow test that revealed a giant Zenker diverticulum. Apart from mildly elevated inflammatory markers and despite the extensive investigation of recurrent fever, no other relevant features were found either in blood analysis, microbiological cultures or computerized tomography. He was submitted to surgical intervention, with no recurrence of fever afterwards. It was assumed that food debris and possible microaspirations were responsible for the recurrence of fever and elevation of inflammatory markers. The patient eventually died due to late complications of surgery. Although recurrent fever is frequently linked to systemic disease, the presence of such a giant diverticulum was probably causing an inflammatory response that is usually not seen in these conditions. (AU)

Decision Making in Severe Equine Asthma-Diagnosis and Monitoring.

Decision making consists of gathering quality data in order to correctly assess a situation and determine the best course of action. This process is a fundamental part of medicine and is what enables practitioners to accurately diagnose diseases and select appropriate treatment protocols. Despite severe equine asthma (SEA) being a highly prevalent lower respiratory disease amongst equids, clinicians still struggle with the optimization of routine diagnostic procedures. The use of several ancillary diagnostic tests has been reported for disease identification and monitoring, but many are only suitable for research purposes or lack practicality for everyday use. The aim of this paper is to assist the equine veterinarian in the process of decision making associated with managing SEA-affected patients. This review will focus on disease diagnosis and monitoring, while also presenting a flow-chart which includes the basic data that the clinician must obtain in order to accurately identify severely asthmatic horses in their everyday routine practice. It is important to note that European and American board-certified specialists on equine internal medicine can provide assistance in the diagnosis and treatment plan of SEA-affected horses.

A Prospective, Observational Cost Comparison of Laparoscopic and Open Appendicectomy in Three Tertiary Hospitals in Nigeria.

BACKGROUND: The clinical benefits of laparoscopic appendicectomy are well recognized over open appendicectomy. However, laparoscopic procedures are not frequently conducted in many low-and middle-income countries (LMICs) for several reasons, including perceived higher costs. The aim of this study was to assess the feasibility and cost of laparoscopic appendicectomy compared to open appendicectomy in Nigeria. METHODS: A multicenter, prospective, cohort study among patients undergoing appendicectomy was conducted at three tertiary hospitals in Nigeria. Data were collected from October 2020 to February 2022 and analyses compared the average healthcare costs at 30 days after surgery. Quantile regression was conducted to identify variables that had an impact on the costs, reported in Nigerian Naira (Naira) and US dollars ($), with standard deviations (SD). FINDINGS: This study included 105 patients, of which 39 had laparoscopic appendicectomy and 66 had open appendicectomy. The average healthcare cost of laparoscopic appendicectomy (147,562 Naira (SD: 97,130) or $355 (SD: 234)) was higher than open appendicectomy (113,556 Naira (SD: 88,559) or $273 (SD: 213)). The average time for return to work was shorter with laparoscopic than open appendicectomy (mean: 8 days vs. 14 days). At the average daily income of $5.06, laparoscopic appendicectomy was associated with 9778 Naira or $24 cost savings in return to work. Further, 5.1% of laparoscopic appendicectomy patients had surgical site infections compared to 22.7% for open appendicectomy. Regression analysis results showed that laparoscopic appendicectomy was associated with $14 higher costs than open appendicectomy, albeit non-significant (p = 0.53). INTERPRETATION: Despite selection bias in this real-world study, laparoscopic appendicectomy was associated with a slightly higher overall cost, a lower societal cost, a lower infection rate, and a faster return to work, compared to open appendicectomy. It is technically and financially feasible, and its provision in Nigeria should be expanded.

Severely Asthmatic Horses Residing in a Mediterranean Climate Shed a Significantly Lower Number of Parasite Eggs Compared to Healthy Farm Mates.

The relationship between helminth infection and allergic diseases has long intrigued the scientific community. This interaction was previously studied in a horse family with high incidence of severe equine asthma and in non-related severely asthmatic horses from equine hospital referrals in Switzerland. Our aim was to determine if this interaction would also be observed in a group of non-related client-owned severely asthmatic horses living in a Mediterranean climate and recruited through a first-opinion veterinarian group. Fecal samples from severe equine asthma-affected and healthy horses living in the same farms and subjected to identical environmental and deworming management were evaluated qualitatively and quantitatively. Strongyle-type eggs and Cyathostomum sensu latum larvae were the most abundant parasites in the studied population of horses; no significant differences between the groups were observed regarding the types of egg and infective larvae. However, we observed significant differences in the number of eggs and infective larvae per gram of feces shed, as this number was significantly lower in the SEA group than in the healthy horses. This may indicate that severely asthmatic horses have an intrinsic resistance to gastrointestinal helminths. Further studies in a larger population of horses are required to ascertain the immunological mechanisms responsible for these findings.

Lithium-Induced Arginine Vasopressin Resistance (AVP-R): A Case of Chronic Exposure to Lithium.

Lithium salts (lithium) is a psychotropic drug widely used as a pharmacological option in managing bipolar disorder. Regular monitoring of serum levels is necessary due to the narrow therapeutic range of lithium. Typically, the diagnosis of lithium intoxication is based on the presence of elevated plasma levels. Nevertheless, poisoning can ensue from either acute ingestion or chronic use, even in patients with normal plasma levels. The utilization of lithium has been decreasing due to its potential for multiorgan toxicity. Lithium accumulation in renal distal tubular cells is a prevalent cause of acquired arginine vasopressin resistance (AVP-R), previously known as nephrogenic diabetes insipidus (DI). Some patients might also experience neurologic persistent symptoms after plasma level normalization, a condition known as the syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). We present a case report of acquired AVP-R following prolonged lithium use. This case report aims to increase awareness, particularly among those who may be unfamiliar with the use of lithium and its associated adverse reactions. In addition, it seeks to highlight the dissociation between clinical manifestations and lithium plasma levels, emphasizing the need for careful evaluation in patients receiving lithium treatment.

Prognostic models for surgical-site infection in gastrointestinal surgery: systematic review.

BACKGROUND: Identification of patients at high risk of surgical-site infection may allow clinicians to target interventions and monitoring to minimize associated morbidity. The aim of this systematic review was to identify and evaluate prognostic tools for the prediction of surgical-site infection in gastrointestinal surgery. METHODS: This systematic review sought to identify original studies describing the development and validation of prognostic models for 30-day SSI after gastrointestinal surgery (PROSPERO: CRD42022311019). MEDLINE, Embase, Global Health, and IEEE Xplore were searched from 1 January 2000 to 24 February 2022. Studies were excluded if prognostic models included postoperative parameters or were procedure specific. A narrative synthesis was performed, with sample-size sufficiency, discriminative ability (area under the receiver operating characteristic curve), and prognostic accuracy compared. RESULTS: Of 2249 records reviewed, 23 eligible prognostic models were identified. A total of 13 (57 per cent) reported no internal validation and only 4 (17 per cent) had undergone external validation. Most identified operative contamination (57 per cent, 13 of 23) and duration (52 per cent, 12 of 23) as important predictors; however, there remained substantial heterogeneity in other predictors identified (range 2-28). All models demonstrated a high risk of bias due to the analytic approach, with overall low applicability to an undifferentiated gastrointestinal surgical population. Model discrimination was reported in most studies (83 per cent, 19 of 23); however, calibration (22 per cent, 5 of 23) and prognostic accuracy (17 per cent, 4 of 23) were infrequently assessed. Of externally validated models (of which there were four), none displayed 'good' discrimination (area under the receiver operating characteristic curve greater than or equal to 0.7). CONCLUSION: The risk of surgical-site infection after gastrointestinal surgery is insufficiently described by existing risk-prediction tools, which are not suitable for routine use. Novel risk-stratification tools are required to target perioperative interventions and mitigate modifiable risk factors.

This study is about finding ways to predict if someone will get an infection after having surgery on their stomach and intestines. If doctors know who is at high risk of getting an infection, they can take steps to prevent it and help the patient recover faster. The researchers looked at all the recent studies that have tried to predict who might get an infection after surgery. They found 23 studies that were good enough to look at in more detail. The researchers found that the studies they looked at were not very good at predicting who might get an infection. Most of the studies did not even check if their predictions were accurate. The few studies that did check were not very good at it. This means that doctors cannot use these predictions to help their patients. This means that doctors need to find better ways to predict who might get an infection after surgery on their stomach and intestines. If they can do this, they can help their patients recover faster and avoid problems like infections.

Effects of a 15° Variation in Poll Flexion during Riding on the Respiratory Systems and Behaviour of High-Level Dressage and Show-Jumping Horses.

From previous studies, the International Society for Equitation Science has advised that further research be conducted on the physiological/psychological effects of less-exacerbated poll flexion angles. We aimed to evaluate the effects of two riding poll flexion positions with a difference of only 15° on the respiratory systems and behaviour of horses through an evaluation of dynamic airway collapse via over-ground endoscopy, the pharyngeal diameter, pleural pressure, arterial oxygenation and lactate, HR/RR, and the occurrence of conflict behaviours. Twenty high-level dressage and twenty show-jumping horses underwent a 40 min ridden test at a ground angle of 85°; 3 weeks later, they underwent a ridden test at a 100° ground angle (the angle between the ground and the line from the forehead to the muzzle) and in a cross-over design. Using a mixed model for repeated measures, Wilcoxon/Friedman tests were carried out according to the experimental design and/or error normality. For both groups, at 100°, conflict behaviours and upper airway tract abnormalities were significantly more frequent, and the pleural pressure was higher, and the pharyngeal diameter was lower. At 85°, relaxation behaviours were significantly more frequent. Lactate was significantly higher at 100° only in the dressage horses. Compared to the first test at 85°, the HR/RR were significantly lower at the beginning of the second test (at 100°) but higher at the end. The significant differences identified in these dressage and show-jumping horses support the idea that an increase of just 15° in riding poll flexion can have negative effects on the respiratory system and behaviour of a horse and therefore on its welfare.

Sexualidade nas pessoas com traumatismo vertebro-medular: Intervenções do enfermeiro especialista em enfermagem de reabilitação / Sexuality in people with spinal cord injury: Interventions by rehabilitation nurses

Enquadramento teórico: A lesão vertebro medular causa um grande impacto na vida das pessoas. A sexualidade é uma parte integrante da vida do ser humano. Quando acometido por uma lesão medular, a pessoa sofre sequelas sensório motoras que condicionam a vivência da atividade sexual. Considerando que, após uma lesão vertebro medular, o ser humano não passa a ser assexuado, é necessário estabelecer um plano de intervenção de Enfermagem de Reabilitação para facilitar a adaptação e conduzir à nova realidade. Objetivos: identificar as dificuldades a nível da sexualidade dos indivíduos que sofrem uma Lesão Vertebro Medular (LVM); identificar as intervenções do Enfermeiro Especialista em Enfermagem de Reabilitação (EEER) para potencializar a funcionalidade, relativamente à sexualidade, das pessoas com LVM. Metodologia: estudo de natureza exploratória, descritiva com abordagem qualitativa do tipo fenomenológico. Nele participaram nove pessoas, duas do sexo feminino e sete do sexo masculino, com idades entre os 20 e os 50 anos. Foi solicitado o preenchimento de um questionário, via email, para os participantes que reuniam os critérios de inclusão. Dos inquiridos que aceitaram fazer parte da amostra, foi realizada a análise das suas respostas, que permitiu entender a vivência da sexualidade no regresso a casa e a intervenção do Enfermeiro Especialista em Enfermagem de Reabilitação (EEER). Resultados: do estudo emergiram quatro áreas principais: a adaptação e as novas aprendizagens; a autoestima; a resposta física; e o papel dos EEER. Conclusões: Os/as participantes expõem que a LVM é um acontecimento devastador e que trouxe grandes alterações/dificuldades relativamente à sua sexualidade. Reconhecendo as limitações inerentes à LVM e analisando as dificuldades e sugestões obtidas, é premente mudar paradigmas da Enfermagem de Reabilitação em relação ao papel do EEER no campo da sexualidade. Deste estudo, fica patente a necessidade de implementar medidas baseadas numa abordagem sem tabus em relação ao sexo, com informações precisas, claras e baseadas na evidência científica que permitam à pessoa e à família uma transição eficaz.

Effect of direct oral anticoagulants versus vitamin K antagonists or warfarin in patients with left ventricular thrombus outcomes: A systematic review and meta-analysis.

INTRODUCTION: Left ventricular thrombus commonly occurs as a complication of acute anterior myocardial infarction and nonischemic cardiomyopathies with severe left ventricular systolic dysfunction. Its frequency is still high despite medical advances. Current guidelines recommend the use of vitamin k antagonists as first-line therapy, however, the off-label use of direct oral anticoagulants is becoming more frequent and attractive, given the better pharmacological and clinical profile, with the improvement of the patient's quality of life. AIM: To provide an update on the currently existing evidence regarding the outcomes of efficacy and safety of direct oral anticoagulants (DOACs) as first-line therapy in left ventricular thrombus, in comparison to vitamin K antagonists (VKAs). METHODS: A systematic review and meta-analysis of studies on the effects of direct oral anticoagulants versus vitamin K antagonists on left ventricular thrombi and on the results was performed. RESULTS: Fourteen studies were included in the meta-analysis, with a total of 2498 patients (n=631 direct oral anticoagulants and n=1867 for VKAs). No significant differences were found in efficacy and safety outcomes (odds ratio (OR) 0.86; 95% confidence interval (CI), 0.55-1.33; p=0.50; I2=32%) and (OR 1.0; 95% CI, 0.78-1.30; p=0.93; I2=2%) respectively. No difference was noted in all-cause mortality (OR 0.92; 95% CI, 0.58-1.45; p=0.74; I2=0%). Thrombus resolution was observed in 288/416 in direct oral anticoagulants vs. 732/1085 patients treated with VKAs (OR 1.14; 95% CI, 0.77-1.66; p=0.50; I2=33%). CONCLUSIONS: The findings of this meta-analysis suggest the potential utility of DOACs as a first-line strategy in patients with left ventricular thrombus.

Training Effects on the Stress Predictors for Young Lusitano Horses Used in Dressage.

The purpose of this study was to investigate stressful responses during a 6-week training protocol in young Lusitano horses used for dressage. The hypothesis was that the proposed training protocol would improve fitness and ensure the welfare of the animals by reducing stress predictors. Nine 4-year-old horses were evaluated before (M1) and six weeks after (M2) beginning a training protocol. The training program was performed six times per week and included 40−80 min of individually intensity-adjusted preparatory exercises for dressage. For both moments, the horses were examined before (T0) and after (T1) dressage simulation tests (DST), and at 30 (T2) and 240 min (T3) during the recovery period. Blood samples were taken to determine the horses' cortisol levels, total WBC, and neutrophil and lymphocyte counts. All variables were analyzed by one-way ANOVA and Tukey tests, with p ≤ 0.05. After training, there was a significant reduction in cortisol (p = 0.0133), HR (p = 0.0283), total WBC (p < 0.0001), and neutrophil (p < 0.0001) and lymphocyte (p = 0.0341) counts. Other findings included an increase in HRV parameters related to a cardiac vagal modulation. In conclusion, the chosen training protocol led to better fitness as the horses worked more intensively with lower cardiovascular requirements, and they showed blunted cortisol responses at M2. Such data can be used to evaluate performance, but also to predict the welfare of athletic horses.

A giant cause of recurrent fever.

A 73-year-old male patient presented to the Emergency Department with history of weight loss, dysphagia, and recurrent fever. The initial chest radiograph showed a mediastinal hypotransparency and to the complaints of dysphagia the patient did a barium swallow test that revealed a giant Zenker diverticulum. Apart from mildly elevated inflammatory markers and despite the extensive investigation of recurrent fever, no other relevant features were found either in blood analysis, microbiological cultures or computerized tomography. He was submitted to surgical intervention, with no recurrence of fever afterwards. It was assumed that food debris and possible microaspirations were responsible for the recurrence of fever and elevation of inflammatory markers. The patient eventually died due to late complications of surgery. Although recurrent fever is frequently linked to systemic disease, the presence of such a giant diverticulum was probably causing an inflammatory response that is usually not seen in these conditions.

Single-phase CT angiography predicts ASPECTS decay and may help determine when to repeat CT before thrombectomy.

OBJETIVES: Time is relative in large-vessel occlusion acute ischemic stroke (LVO-AIS). We aimed to evaluate the rate of inter-hospital ASPECTS decay in patients transferred from a primary (PSC) to a comprehensive stroke center (CSC); and to identify patients that should repeat computed tomography (CT) before thrombectomy. MATERIALS AND METHODS: This was a retrospective cohort study of consecutive anterior circulation LVO-AIS transferred patients. The rate of ASPECTS decay was defined as (PSC-ASPECTS - CSC-ASPECTS)/hours elapsed between scans. Single-phase CT angiography (CTA) at the PSC was used to classify the collateral score. We compared patients with futile versus useful CT scan re-evaluation. RESULTS: We included 663 patients, of whom 245 (37.0%) repeated CT at a CSC. The median rate of ASPECTS decay was 0.4/h (0.0-0.9). Patients excluded from thrombectomy after a CT scan repeat (n=64) had a median ASPECTS decay rate of 1.18/h (0.83-1.61). Patients with absent collateral circulation had a median rate of 1.51(0.65-2.19). The collateral score was an independent predictor of the ASPECTS decay rate (aß = -0.35; 95%CI -0.45 - -0.19, p<0.001). Age (aOR: 1.04 95% CI 1.02-1.07, p<0.001), NIHSS (aOR: 1.11 95% CI 1.06-1.15, p<0.001), PSC ASPECTS (aOR: 0.74 95% CI 0.60-0.91, p=0.006) and the CTA collateral score (aOR: 0.14 95% CI 0.08-0.22, p<0.001) were independent predictors of the usefulness of a CT scan repeat. CONCLUSIONS: The rate of ASPECTS decay can be predicted by the CTA collateral score, helping in the selection of patients that would benefit from repeating a CT assessment on arrival at the CSC.