Validation of the transcranial Doppler rescue criteria for mechanical thrombectomy.

BACKGROUND AND PURPOSE: Transcranial Doppler (TCD) identifies acute stroke patients with arterial occlusion where treatment may not effectively open the blocked vessel. This study aimed to examine the clinical utility and prognostic value of TCD flow findings in patients enrolled in a multicenter prospective study (CLOTBUST-PRO). METHODS: Patients enrolled with intracranial occlusion on computed tomography angiography (CTA) who underwent urgent TCD evaluation before intravenous thrombolysis was included in this analysis. TCD findings were assessed using the mean flow velocity (MFV) ratio, comparing the reciprocal ratios of the middle cerebral artery (MCA) depths bilaterally (affected MCA-to-contralateral MCA MFV [aMCA/cMCA MFV ratio]). RESULTS: A total of 222 patients with intracranial occlusion on CTA were included in the study (mean age: 64 ± 14 years, 62% men). Eighty-eight patients had M1 MCA occlusions; baseline mean National Institutes of Health Stroke Scale (NIHSS) score was 16, and a 24-hour mean NIHSS score was 10 points. An aMCA/cMCA MFV ratio of <.6 had a sensitivity of 99%, specificity of 16%, positive predictive value (PV) of 60%, and negative PV of 94% for identifying large vessel occlusion (LVO) including M1 MCA, terminal internal carotid artery, or tandem ICA/MCA. Thrombolysis in Brain Ischemia scale, with (grade ≥1) compared to without flow (grade 0), showed a sensitivity of 17.1%, specificity of 86.9%, positive PV of 62%, and negative PV of 46% for identifying LVO. CONCLUSIONS: TCD is a valuable modality for evaluating arterial circulation in acute ischemic stroke patients, demonstrating significant potential as a screening tool for intravenous/intra-arterial lysis protocols.

Ivor Lewis Esophagectomy and the Care of Humphrey Bogart's Midesophageal Cancer.

In 1945, the Welsh surgeon Ivor Lewis first reported performing the resection of a midesophageal tumor through a combined approach involving the abdomen and right chest. Although his technique was initially rebuffed by the preeminent esophageal surgeons of the time, it quickly became the standard approach for cancers of the midesophagus. Here we review the development and early dissemination of Lewis' operation using the case of the American actor Humphrey Bogart, who underwent an Ivor Lewis esophagectomy for esophageal cancer in 1956.

Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation.

BACKGROUND: Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing. METHODS: Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression. RESULTS: There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO. CONCLUSIONS: Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.

Forensic Analysis of the Abraham Lincoln Assassination: An On-Site Study of the Presidential Box at Ford's Theatre.

ABSTRACT: On April 14, 1865, Abraham Lincoln was assassinated while watching a play from the Presidential Box at Ford's Theatre in Washington, DC. There is still controversy concerning the findings of Lincoln's autopsy. The physicians that attended the autopsy documented that the bullet entered the left occipital region of the brain, but opinions differ as to the path the bullet took through the brain. The official autopsy report documented that the bullet traveled through the left brain and did not cross the midline. Others who watched the autopsy claimed that the bullet entered on the left side of the president's brain, crossed the midline, and ended up just above the orbit on the right. In this manuscript, we reviewed all of the statements of the witnesses to the assassination in an effort to reconstruct the approach that John Wilkes Booth, the assassin, took through the Presidential Box as he approached the president. In addition, we conducted an on-site analysis of the shape and dimensions of the Presidential Box at Ford's Theatre to support the approach that Booth took. Based on this forensic analysis, we provide supportive evidence that the findings of the official autopsy report are accurate; that is, the bullet that entered the president's left brain stayed on the left and did not cross the midline.

Development and Validation of a Claims-Based Model to Predict Categories of Obesity.

We developed and validated a claims-based algorithm that classifies patients into obesity categories. Using Medicare (2007-2017) and Medicaid (2000-2014) claims data linked to 2 electronic health record (EHR) systems in Boston, Massachusetts, we identified a cohort of patients with an EHR-based body mass index (BMI) measurement (calculated as weight (kg)/height (m)2). We used regularized regression to select from 137 variables and built generalized linear models to classify patients with BMIs of ≥25, ≥30, and ≥40. We developed the prediction model using EHR system 1 (training set) and validated it in EHR system 2 (validation set). The cohort contained 123,432 patients in the Medicare population and 40,736 patients in the Medicaid population. The model comprised 97 variables in the Medicare set and 95 in the Medicaid set, including BMI-related diagnosis codes, cardiovascular and antidiabetic drugs, and obesity-related comorbidities. The areas under the receiver-operating-characteristic curve in the validation set were 0.72, 0.75, and 0.83 (Medicare) and 0.66, 0.66, and 0.70 (Medicaid) for BMIs of ≥25, ≥30, and ≥40, respectively. The positive predictive values were 81.5%, 80.6%, and 64.7% (Medicare) and 81.6%, 77.5%, and 62.5% (Medicaid), for BMIs of ≥25, ≥30, and ≥40, respectively. The proposed model can identify obesity categories in claims databases when BMI measurements are missing and can be used for confounding adjustment, defining subgroups, or probabilistic bias analysis.

Performance assessment of surgical tracking systems based on statistical process control and longitudinal QA.

A system for performance assessment and quality assurance (QA) of surgical trackers is reported based on principles of geometric accuracy and statistical process control (SPC) for routine longitudinal testing. A simple QA test phantom was designed, where the number and distribution of registration fiducials was determined drawing from analytical models for target registration error (TRE). A tracker testbed was configured with open-source software for measurement of a TRE-based accuracy metric ε and Jitter (J). Six trackers were tested: 2 electromagnetic (EM - Aurora); and 4 infrared (IR - 1 Spectra, 1 Vega, and 2 Vicra) - all NDI (Waterloo, ON). Phase I SPC analysis of Shewhart mean (x¯) and standard deviation (s) determined system control limits. Phase II involved weekly QA of each system for up to 32 weeks and identified Pass, Note, Alert, and Failure action rules. The process permitted QA in <1 min. Phase I control limits were established for all trackers: EM trackers exhibited higher upper control limits than IR trackers in ε (EM: x¯Îµ âˆ¼2.8-3.3 mm, IR: x¯Îµ âˆ¼1.6-2.0 mm) and Jitter (EM: x¯jitter âˆ¼0.30-0.33 mm, IR: x¯jitter âˆ¼0.08-0.10 mm), and older trackers showed evidence of degradation - e.g. higher Jitter for the older Vicra (p-value < .05). Phase II longitudinal tests yielded 676 outcomes in which a total of 4 Failures were noted - 3 resolved by intervention (metal interference for EM trackers) - and 1 owing to restrictive control limits for a new system (Vega). Weekly tests also yielded 40 Notes and 16 Alerts - each spontaneously resolved in subsequent monitoring.

A "New" Nonmesh Technique for Inguinal Hernia Repair: Revisiting E. Wyllys Andrews and His Imbricating Operation.

The use of prosthetic mesh to repair inguinal hernias has been common practice at surgical centers around the world for more than 30 years. Open tissue repairs are the alternative for patients who cannot have, do not want, or are not offered mesh. Open tissue repairs are troubled by inferior recurrence rates in most clinical trials. In this article, we will review a long-forgotten tissue repair described by Andrews in 1895. In addition, we report on our early experience with the Andrews technique for primary inguinal hernia tissue repair.

Richard Nixon's Left Knee and Its Impact on American History.

Richard Nixon injured his left knee in a limousine door while campaigning in North Carolina in 1960, resulting in septic arthritis that required a multi-day admission to Walter Reed Hospital. Still ill for the first presidential debate that fall, Nixon lost the contest based more on his appearance than his performance. Partly as a result of this debate, he was defeated by John F. Kennedy in the general election. Because of his leg wound, Nixon developed chronic DVTs in that limb, including a severe thrombus in 1974 that embolized to his lung, required surgery, and prevented him from testifying at the Watergate Trial. Episodes like this one highlight the value of studying the health of famous figures, where even the most minor injuries have the potential to influence world history.

Psychophysics of Pain: A Methodological Introduction.

For over 100 years, psychophysics ..÷ the scientific study between physical stimuli and sensation ... has been successfully employed in numerous scientific and healthcare disciplines, as an objective measure of sensory phenomena. This manuscript provides an overview of fundamental psychophysical concepts, emphasizing pain and research application..÷defining common terms, methods, and procedures.Psychophysics can provide systematic and objective measures of sensory perception that can be used by nursing scientists to explore complex, subjective phenomena..÷such as pain perception. While there needs to be improved standardization of terms and techniques, psychophysical approaches are diverse and may be tailored to address or augment current research paradigms. The interdisciplinary nature of psychophysics..÷like nursing..÷provides a unique lens for understanding how our perceptions are influenced by measurable sensations. While the quest to understand human perception is far from complete, nursing science has an opportunity to contribute to pain research by using the techniques and methods available through psychophysical procedures.

Surgical Site Infection After Primary Spinal Fusion Surgery for Adolescent Idiopathic Scoliosis: An Analysis of Risk Factors From a Nationwide Insurance Database.

STUDY DESIGN: Retrospective review. OBJECTIVE: The purpose of this study was to quantify the incidence and factors associated with surgical site infection (SSI) in pediatric patients undergoing spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Infection is a morbid complication after spinal fusion. The incidence of SSI after pediatric spinal fusion is likely underestimated; the use of a national database allows for a comprehensive assessment of this rare outcome. MATERIALS AND METHODS: The PearlDiver Database was used to identify AIS patients who underwent primary instrumented spinal fusion between 2010 and 2019 and relevant patient records were queried to identify infections within 7, 30, and 90 postoperative days. Patients with nonidiopathic scoliosis were excluded. Logistic regression was used to evaluate risk factors associated with postoperative infection. RESULTS: Out of 9801 patients who underwent primary fusion for AIS, 44 patients (0.4%) developed an infection within 7 postoperative days. The 30 days and 90 days incidences were 1.9% and 2.7%, respectively. Within 90 days, 154 (57.7%) of the patients with infection had undergone reoperation, of whom 72 underwent multiple reoperations. Obesity and male sex ( P < 0.05) were significantly associated with postoperative infection. The length of fusion was not a significant factor in the development of SSI ( P > 0.05). Eleven patients underwent an operation requiring hardware removal within 90 days. There were no significant factors associated with those undergoing hardware removal compared with those undergoing surgical debridement. CONCLUSIONS: The study identified a 2.7% 90 days incidence of SSI after posterior spinal fusion for AIS, with 57.7% of all infections requiring a return to the operating room. Preoperative patient-related characteristics associated with increased risk of postoperative SSI were male sex and obesity. The current study can be used to provide preoperative counseling regarding the risk of this postoperative complication. LEVEL OF EVIDENCE: Level III.

Venous Thromboembolic Events are Exceedingly Rare in Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Review of health care record database and determination of population statistics. OBJECTIVE: The purpose of this study was to quantify the incidence of clinically significant venous thromboembolic (VTE) events in patients undergoing spinal fusion surgery for adolescent idiopathic scoliosis (AIS) and to identify risk factors for VTE. SUMMARY OF BACKGROUND DATA: VTE is a serious complication that can cause disability and even death following surgery. Incidence of VTE following AIS surgery has not been well studied; the use of a national database allows the assessment of rare, yet important complications. MATERIALS AND METHODS: The PearlDiver Database was used to identify AIS patients who underwent primary instrumented spinal fusion between 2010 and 2020. Patient records were cross-referenced for documented VTEs within 30 and 90 postoperative days. Patients with nonidiopathic scoliosis were excluded. Logistic regression was used to evaluate risk factors for correlation with VTE events. RESULTS: Thirty-eight of 11,775 (0.323%) patients undergoing surgery for AIS developed a VTE complication within 90 postoperative days. Hypercoagulability [odds ratio (OR)=13.50, P <0.0001], spinal fusion involving 13+ vertebral levels (OR=2.61, P <0.0001), obesity (OR=1.30, P <0.005), and older (15-18 y) compared with younger adolescence (10-14 y) (OR=2.12, P <0.0001) were associated with VTE. Seven of 38 (18.4%) patients with a diagnosed thrombophilia experienced VTE. CONCLUSIONS: The incidence of clinically significant VTEs in pediatric patients following spinal fusion surgery for AIS is low with an incidence of 0.323%. Postoperative chemoprophylaxis in the general pediatric population is not indicated. Patients with obesity, those undergoing spinal fusion of 13 or more vertebrae, and adolescents 15-18 years old were found to have higher but still small risk of VTE following surgery. Further prospective studies are needed to validate the risk profile of patients with hypercoagulability and establish clinical guidelines for use of postoperative chemoprophylaxis in this cohort. LEVEL OF EVIDENCE: Level III.

"The President's Syndrome": The Diagnosis and Treatment of Gerald Ford's Lingual Actinomycosis.

Gerald R. Ford was the 38th president of the United States. He was appointed as vice president by Richard Nixon in 1974 upon the resignation of Spiro T. Agnew. In the midst of the Watergate Crisis, Nixon resigned making Ford the only president to serve without being elected as either president or vice president. In the year 2000, 13 years after his abbreviated term in office, he was attending the Republican National Convention in Philadelphia where he developed pain in his tongue, slurring of his speech, and signs of a stroke. He was taken to the emergency room of Hahnemann University Hospital where a CT scan showed a posterior circulation stroke. Within 24 hours, all of Ford's symptoms improved except for his tongue pain and speech. An MRI of the head and neck showed a tongue mass and he was taken to the operating room where an abscess was found. The bacteriology confirmed actinomycosis of the tongue and Ford rapidly improved after the incision and drainage. This paper will review the clinical course of Gerald Ford's lingual actinomycosis and will discuss this rare condition.

Medicine and History: a Surgical Model for National Integration.

Historians and physicians have struggled to incorporate history into American medical education for over a century. Most efforts focus on local initiatives targeting a narrow audience. We describe a novel method involving the American College of Surgeons, a national organization with tens of thousands of members. Capitalizing on its infrastructure and influence over the field, we have implemented a variety of ventures that include panel sessions at meetings, poster competitions, travel grants, themed breakfasts, online communities, and other such projects. This programming has reached thousands of participants, ranging from pre-medical students to retired physicians, and it has increased both the exposure to and production of surgical history. Our article describes the process of establishing this nationally coordinated enterprise in the hopes that other medical specialties can emulate it and further the study of and appreciation for medical history.

All-Suture Suspensory Button Has Similar Biomechanical Performance to Metal Suspensory Button for Onlay Subpectoral Biceps Tenodesis.

Purpose: To evaluate the maximal load at failure, cyclic displacement, and stiffness of onlay subpectoral biceps tenodesis (BT) with an intramedullary unicortical metal button (MB) versus a unicortical all-suture button (ASB). Methods: Eighteen matched paired human cadaveric proximal humeri were randomly allocated for subpectoral BT with either ASB or MB using a high-strength suture. Specimens were tested on a servohydraulic mechanical testing apparatus under cyclic load for 1,000 cycles and then loaded to failure. The clamp was then adjusted to isolate the suture-anchor point interface and loaded to failure. Maximal load to failure, displacement, and stiffness were compared. Results: There was no significant difference between groups in stiffness, displacement, or yield load. The maximal load to failure for the MB was greater than the ASB (347.6 ± 74.1N vs 266.5 ± 69.3N, P = .047). Eight specimens in each group failed by suture pull-through on the tendon. When the suture-anchor point interface was isolated, there was no significant difference in maximal load at failure (MB 586.5 ± 215.8N vs ASB 579.6 ± 255.9N, P = .957). Conclusions: This study demonstrates that the MB and ASB have similar biomechanical performance when used in subpectoral BT. Although the MB showed statistically significant greater maximal load to failure, there was no difference between the MB and ASB when the suture-tendon interface was eliminated. Suture pull-through was the most common mode of failure for both implants, underscoring the importance of the suture-tendon interface. Clinical Relevance: Fixation techniques for the treatment of long head of the biceps brachii tenodesis continue to evolve. The use of an all-suture suspensory button has advantages, but it is important to understand if this implant is a biomechanically suitable alternative to a metal suspensory button.

Multi-perspective region-based CNNs for vertebrae labeling in intraoperative long-length images.

PURPOSE: Effective aggregation of intraoperative x-ray images that capture the patient anatomy from multiple view-angles has the potential to enable and improve automated image analysis that can be readily performed during surgery. We present multi-perspective region-based neural networks that leverage knowledge of the imaging geometry for automatic vertebrae labeling in Long-Film images - a novel tomographic imaging modality with an extended field-of-view for spine imaging. METHOD: A multi-perspective network architecture was designed to exploit small view-angle disparities produced by a multi-slot collimator and consolidate information from overlapping image regions. A second network incorporates large view-angle disparities to jointly perform labeling on images from multiple views (viz., AP and lateral). A recurrent module incorporates contextual information and enforce anatomical order for the detected vertebrae. The three modules are combined to form the multi-view multi-slot (MVMS) network for labeling vertebrae using images from all available perspectives. The network was trained on images synthesized from 297 CT images and tested on 50 AP and 50 lateral Long-Film images acquired from 13 cadaveric specimens. Labeling performance of the multi-perspective networks was evaluated with respect to the number of vertebrae appearances and presence of surgical instrumentation. RESULTS: The MVMS network achieved an F1 score of >96% and an average vertebral localization error of 3.3 mm, with 88.3% labeling accuracy on both AP and lateral images - (15.5% and 35.0% higher than conventional Faster R-CNN on AP and lateral views, respectively). Aggregation of multiple appearances of the same vertebra using the multi-slot network significantly improved the labeling accuracy (p < 0.05). Using the multi-view network, labeling accuracy on the more challenging lateral views was improved to the same level as that of the AP views. The approach demonstrated robustness to the presence of surgical instrumentation, commonly encountered in intraoperative images, and achieved comparable performance in images with and without instrumentation (88.9% vs. 91.2% labeling accuracy). CONCLUSION: The MVMS network demonstrated effective multi-perspective aggregation, providing means for accurate, automated vertebrae labeling during spine surgery. The algorithms may be generalized to other imaging tasks and modalities that involve multiple views with view-angle disparities (e.g., bi-plane radiography). Predicted labels can help avoid adverse events during surgery (e.g., wrong-level surgery), establish correspondence with labels in preoperative modalities to facilitate image registration, and enable automated measurement of spinal alignment metrics for intraoperative assessment of spinal curvature.

Dynamics of microbial populations and metabolites of fermenting saps throughout tapping process of ron and oil palm trees in Côte d'Ivoire.

Palm wine fermentation is a complex microbial process that evolves with tapping times. The dynamics in microbiota and metabolites throughout palm wine tapping days is still not established, which are critical for the distinctive characteristics of palm wine taste and quality, and thus the mastery of the daily quality fluctuation during tapping. We analyzed the changes in microbial community structure by amplicon sequencing of bacterial 16S rRNA gene and fungal internal transcribed spacer (ITS) region, and metabolite profile changes using mass spectrometry in palm wine collected over 25-30 days tapping of ron (Borassus aethiopum) and oil palms (Elaeis guineensis) from Côte d'Ivoire. The stage-wise collected palm wine samples showed distinct changes in microbial diversity and pH, supporting microbial community dynamics during palm wine tapping. Results highlighted the dominance of Saccharomyces cerevisiae in early stages and the emergence of non-Saccharomyces yeasts, particularly Hanseniaspora spp. in the later stages of oil palm wine tapping, vice versa in the case of ron palm wine tapping, with a unique presence of Saccharomycodes in the later stages (15-30 days). Fructophilic lactic acid bacteria (FLAB), mainly Fructobacillus and Leuconostoc, encountered in both types of palm wine tapping showed a decline at later stages of oil palm wine tapping. In this type of palm wine, acetic acid bacteria with genera Acetobacter and Glucanoacetobacter, by surpassing Lactobacillus in the last stage become dominant, whereas Lactobacillus remained dominant in ron palm wine throughout tapping days. The decline in the relative abundance of gevotroline and essential amino acids during the later stages of palm wine tapping (15-25 days) supports the difference in the health benefits of the palm wine obtained from different days of tapping, indicating that early stages of tapping is more nutritional and healthy than the later stages. The microbial dynamics may be a potential indicator of metabolite changes during palm sap fermentation, thus contributing to establish particular features of palm wines in different stages of tapping. This understanding of microbial ecology and chemical composition changes during palm wine tapping can be used as biomarkers to assess palm wine's quality and help to design an optimum starter culture.