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Characterizing Olfactory Dysfunction in Patients with Unilateral Cleft Lip Nasal Deformities.
No full textBackground: Unilateral cleft lip nasal deformity (uCLND) is associated with olfactory dysfunction, but the underlying etiology remains poorly understood. Objective: To investigate the etiology of uCLND-associated olfactory dysfunction using clinical, computational, and histologic assessments. Methods: Inclusion criteria: uCLND patients >16 years undergoing septorhinoplasty. Exclusion criteria: prior septoplasty or rhinoplasty, pregnancy, sinusitis. Measured outcomes: patient-reported scores, rhinomanometry, smell identification and threshold tests, computational fluid dynamics (CFD) airflow simulations, and histologic analysis of olfactory epithelium. Results: Five uCLND subjects were included: 18-23 years, three male and two female, four left-sided cleft and one right-sided cleft. All subjects reported moderate to severe nasal obstruction. Smell identification and threshold tests showed varying degrees of hyposmia. Nasal resistance was higher on the cleft side versus noncleft side measured by rhinomanometry (median 3.85 Pa-s/mL, interquartile range [IQR] = 21.96, versus 0.90 Pa-s/mL, IQR = 5.17) and CFD (median 1.04 Pa-s/mL, IQR = 0.94 vs. 0.11 Pa-s/mL, IQR = 0.12). Unilateral olfaction varied widely and was dependent on unilateral percentage olfactory airflow. Biopsies revealed intact olfactory neuroepithelium. Conclusions: uCLND-associated olfactory dysfunction appears to be primarily conductive in etiology and highly susceptible to variations in nasal anatomy. Clinical Trial Registration number: NCT04150783
Risk of venous thromboembolism in patients with ankylosing spondylitis: A systematic review and meta-analysis
No full textIntroduction: Altered mental status is one of the most common presentations that leads to an admission to intensive care unit. Posterior reversible encephalopathy syndrome (PRES), which is commonly encountered in association with various medical conditions, is an uncommon but probably under-diagnosed cause of this presentation.
Case report: A 51-year-old woman was admitted to our ICU because of alteration of consciousness. She was in her usual state of health the night before although she complained of a mild headache. She became unarousable on the following morning and her husband immediately brought her to our institution. She had a significant history of SLE that was diagnosed five years ago with malar rash, photosensitivity rash, polyarthritis, positive ANA and anti-smith antibody. Her only current medication was hydroxychloroquine. Upon admission, she was found to be hypertensive with BP of 170/90 mmHg. Neurological examination was remarkable for GCS of five without any focal neurological deficit. Laboratory investigations were remarkable for an elevation of creatinine (2.4 mg/dL from baseline of 1.0 mg/dL) and an abnormal urinalysis with numerous dysmorphic RBCs and WBCs. CT brain demonstrated ill-defined hypodensity in the subcortical white matter of both posterior parietal lobes. A subsequent MRI brain revealed T2 hyper-intense signal in cortex and subcortical white matter of the same lobes (Figure). She was diagnosed with PRES and was immediately treated with intravenous labetalol. Her BP gradually came down to normal range and her mental status gradually improved as she became completely alert and oriented on the fourth day of admission. She underwent renal biopsy during this admission which revealed type IV lupus nephritis. Treatment with steroid and cyclophosphamide was initiated.
Comment: Patient with PRES usually presents with headache, seizure, nausea, confusion or coma in a more severe case. A broad range of medical conditions, including hypertension, eclampsia, use of immunosuppressive agent, and autoimmune disorders has been implicated as causes of this syndrome. Neuroimaging is crucial to the diagnosis. Typical findings include symmetrical edema of white matter predominantly in the parieto-occipital lobes. These abnormalities are best depicted by MRI (hyper-intense signal on T2 and FLAIR technique). Prognosis is favorable as the neurological deficit is usually reversible in days to weeks after blood pressure control, as seen in this patient. However, delay in initiating the appropriate treatment can lead to a permanent neurological damage. Thus, physician should have a high index of suspicion for this syndrome especially in patients with known associated illnesses
Upper thoracic versus lower thoracic upper instrumented vertebrae endpoints have similar outcomes and complications in adult scoliosis.
No full textStudy designRetrospective review-multicenter database.ObjectiveThe purpose of this study was to compare the upper thoracic (UT) and lower thoracic (LT) upper instrumented vertebrae (UIV) in long fusions to the sacrum for adult scoliosis.Summary of background dataThe optimal UIV for stopping long fusions to the sacrum/pelvis are controversial. Although a UT endpoint may lead to greater operative times, blood loss, and higher rates of pseudarthrosis, the risk for the development of proximal junctional kyphosis and need for revision surgery is likely lower.MethodsRetrospective analysis of a prospective database of patients with adult spinal deformity, Patients were selected on the basis of fusions to the sacrum/pelvis with UIV of T1-T6 (UT group) and those with a UIV of T9-L1 (LT group). Demographic data, operative details, and radiographical outcomes with Scoliosis Research Society scores, and Oswestry Disability Index outcomes were collected, as well as complication data were compared. The Fisher exact T tests were used for statistical analysis.ResultsA total of 198 patients (UT = 91, LT = 107) with a mean age of 61.6 were followed for an average of 2.5 years. Demographic variables were similar between the groups except for larger numbers of females in the UT group and a slightly higher body mass index in the LT group. Preoperatively, the UT group demonstrated significantly more lumbar scoliosis, thoracic scoliosis, and thoracolumbar kyphosis. The UT group demonstrated a larger number of fused segments length of stay and longer operative times. There was slightly larger volume of blood loss in the UT group.The total number of complications and number of revision surgical procedures were similar between the groups. The UT group had a higher percentage of patients with 2 or more complications. Both groups had similar proximal junctional kyphosis angles and number of cases requiring revision for proximal junctional kyphosis. Scoliosis Research Society and Oswestry Disability Index outcomes were similar between the groups.ConclusionThe UT and LT groups had similar outcomes. The UT group may have a higher rate of total complications, but major complications requiring return to the operative room were similar. The length of stay and operative times were higher in the UT group but may have been necessarily evidenced by the significantly higher coronal deformity and greater thoracolumbar kyphosis in the UT group.Level of evidence4
A Radiomics-Incorporated Deep Ensemble Learning Model for Multi-Parametric MRI-based Glioma Segmentation
No full textAbstractPurpose: To develop a deep ensemble learning model with a radiomics spatial encoding execution for improved glioma segmentation accuracy using multi-parametric MRI (mp-MRI).
Materials/Methods: This radiomics-incorporated deep ensemble learning model was developed using 369 glioma patients with a 4-modality mp-MRI protocol: T1, contrast-enhanced T1 (T1-Ce), T2, and FLAIR. In each modality volume, a 3D sliding kernel was implemented across the brain to capture image heterogeneity: fifty-six radiomic features were extracted within the kernel, resulting in a 4th order tensor. Each radiomic feature can then be encoded as a 3D image volume, namely a radiomic feature map (RFM). For each patient, all RFMs extracted from all 4 modalities were processed by the Principal Component Analysis (PCA) for dimension reduction, and the first 4 principal components (PCs) were selected. Next, four deep neural networks following the U-net’s architecture were trained for the segmenting of a region-of-interest (ROI): each network utilizes the mp-MRI and 1 of the 4 PCs as a 5-channel input for 2D execution. Last, the 4 softmax probability results given by the U-net ensemble were superimposed and binarized by Otsu’s method as the segmentation result. Three deep ensemble models were trained to segment enhancing tumor (ET), tumor core (TC), and whole tumor (WT), respectively. Segmentation results given by the proposed ensemble were compared to the mp-MRI-only U-net results.
Results: All 3 radiomics-incorporated deep learning ensemble models were successfully implemented: Compared to mp-MRI-only U-net results, the dice coefficients of ET (0.777→0.817), TC (0.742→0.757), and WT (0.823→0.854) demonstrated improvements. Accuracy, sensitivity, and specificity results demonstrated the same patterns.
Conclusion: The adopted radiomics spatial encoding execution enriches the image heterogeneity information that leads to the successful demonstration of the proposed neural network ensemble design, which offers a new tool for mp-MRI-based medical image segmentation.
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Recurrent Cryptogenic Stroke in a Young Woman: Congenital Thrombotic Thrombocytopenic Purpura Unmasked
No full textAlignment Risk Factors for Proximal Junctional Kyphosis and the Effect of Lower Thoracic Junctional Tethers for Adult Spinal Deformity.
No full textObjectiveThe aims of this retrospective cohort study were to 1) identify new alignment risk factors for proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients with lower thoracic upper instrumented vertebra (UIV) and 2) determine the effect of junctional tethers on PJK and UIV alignment.MethodsWe analyzed consecutive ASD patients who underwent posterior instrumented fusion with lower thoracic UIV (T9-T11). Posteriorly anchored junctional tethers were used more recently for ligamentous augmentation to prevent PJK. In addition to regional and global parameters, upper segmental lumbar lordosis (ULL) versus lower segmental lumbar lordosis and UIV angle (measured from UIV inferior endplate to horizontal) were assessed. Primary outcome of PJK was defined as proximal junctional angle >10° and >10° greater than the corresponding preoperative measurement. Univariable and multivariable analyses were performed.ResultsThe study cohort comprised 120 ASD patients (mean age, 67 years) with minimum 1-year follow-up. Preoperative ULL (P = 0.034) and UIV angle (P = 0.026) were associated with PJK. No independent preoperative alignment risk factors of PJK were identified in multivariable analysis. Tether use was protective against PJK (odds ratio, 0.063 [0.016-0.247]; P ConclusionsJunctional tethers significantly reduced PJK in ASD patients with lower thoracic UIV. In tethered patients, PJK was more common with greater postoperative lordosis of the upper lumbar spine and greater UIV angle. This finding suggests potential benefit of tethers to mitigate effects of segmental lumbar and focal UIV malalignment that may occur after deformity surgery
A multilevel mHealth intervention boosts adherence to hydroxyurea in individuals with sickle cell disease.
No full textHydroxyurea reduces sickle cell disease (SCD) complications, but medication adherence is low. We tested two mobile health (mHealth) interventions targeting determinants of low adherence among patients (InCharge Health) and low prescribing among providers (HU Toolbox) in a multi-center non-randomized trial of individuals with SCD ages 15-45. We compared the percentage of days covered (PDC), labs, healthcare utilization, and self-reported pain over 24 weeks of intervention and 12 weeks post-study with a 24-week pre-intervention interval. We enrolled 293 patients (51% male; median age 27.5 years, 86.8% HbSS/HbSβ0-thalassemia). The mean change in PDC among 235 evaluable subjects increased (39.7% to 56.0%; por=1 day by 199 of 235 participants (84.7% implementation; median usage: 17% study days; IQR: 4.8-45.8%). For individuals with >or=1 baseline admission for pain, admissions per 24 weeks declined from baseline through 24 weeks (1.97 to 1.48 events/patient, p=0.0045) and weeks 25-36 (1.25 events/patient, p=0.0015). PDC increased with app use(por=1/month on average. This use did not affect change in PDC. Tailoring mHealth solutions to address barriers to hydroxyurea adherence has the potential to improve adherence and provide clinical benefits. A definitive randomized study is warranted
Health-Related Quality of Life Scores Underestimate the Impact of Major Complications in Lumbar Degenerative Scoliosis Surgery.
No full textStudy designRetrospective cohort.ObjectiveTo examine Charlson Comorbidity Index (CCMI) as a marker for deterioration in health status not reflected in standard Health Related Quality of Life (HRQOL) measures.Summary of background dataHRQOL has become a primary metric for assessing outcomes following spinal deformity surgery. However, studies have reported limited impact of complications on postoperative HRQOL outcomes.MethodsWe examined serial CCMI, complications, and HRQOL outcomes for 138 adult lumbar deformity patients treated surgically with a minimum two-year follow-up that included 126 females (91%) with a mean age of 59.8 years (range, 40.2-78.5). Patients with no, minor, or major complications were compared at baseline and at one and two years postoperation.ResultsMinor complications were observed in 26 patients (19%) and major complications in 15 (11%). Major complications included motor deficit (7), deep vein thrombosis (4), and respiratory failure (3). There was no difference in preoperative SF-36 Physical Component Summary or Scoliosis Research Society-22R (SRS-22R) scores among the groups at baseline. Preoperative CCMI was lowest in the No Complication group (3.52 ± 1.70) followed by the Major (4.00 ± 1.13) and Minor Complication groups (4.15 ± 1.71, p = .165). At one year, there was a significantly greater CCMI deterioration in the Major Complication group (0.80 ± 1.01) compared to both the Minor (0.08 ± 0.27) and No Complication groups (0.27 ± 0.47, p ConclusionsDespite similar one- and two-year HRQOL improvement, patients with major complications had greater deterioration in CCMI. As CCMI is predictive of medical and surgical risk, patients who sustained a major complication now carry a greater likelihood of adverse outcomes with future interventions, including any subsequent spinal surgery. Although this increased risk may not alter the patient's perception of his or her current health status, it may be important, and should be recognized as part of the shared decision-making process.Level of evidenceLevel II, high-quality prognostic study
Designing an Intervention to Improve MI Care in a Tanzanian Emergency Department
No full textBackground: Myocardial Infarction (MI) was previously thought to be rare in sub-Saharan Africa (SSA) but a growing body of evidence suggests MI is in reality under-diagnosed. Multiple studies from Tanzania show there is a need for intervention to improve MI diagnosis, treatment, and outcomes. Our objective was to create an intervention targeting MI care in the emergency department of a Tanzanian referral hospital. Methods: To address this gap an interdisciplinary group of individuals from Tanzania and the United States formed a Design Team to co-create an intervention. The group utilized the ADAPT-ITT model to guide the process of assessing need, identifying an intervention to adapt, and begin the process of adaptation and production to meet the needs of the target population. Results: In the Assessment phase, the team found substantial under-diagnosis of MI, a low rate of aspirin administration, and a lack of both patient and provider awareness. In the Decision phase, the team reviewed 10 interventions of various types before deciding upon the BRIDGE-ACS study as an ideal target for adaptation. In the Adaptation phase, the team discussed intervention content with a focus on ensuring appropriateness for local context. The team is currently in the Production phase creating the necessary materials for implementation of the intervention. Conclusions: In the emergency department of a Tanzanian referral hospital, intervention is needed to improve MI diagnosis, treatment, and outcomes. While the adaptation process is still ongoing, this paper can serve as a guide for others wanting to engage in collaborative intervention development targeting clinical care. </p
Measuring attention in rats with a visual signal detection task: Signal intensity vs. signal duration.
No full textMeasurement of attentional performance in animal behavioral research allows us to investigate neural mechanisms underlying attentional processes and translate results to better understand human attentional function, dysfunction and drug treatments to reverse dysfunction. One useful method to measure attention in experimental animal studies is to use an operant visual signal detection paradigm, consisting of two levers and the rapid flashing of a cue lamp to signal a reward. In this study, we tested the relative sensitivity of this task when using different variants of the stimulus signal, varying brightness or duration of the light cue. To investigate roles of different neural systems underlying attentional processes, we assessed the sensitivity of attentional performance with these two different cue variations with blockade of muscarinic acetylcholine and NMDA glutamate receptors with scopolamine and MK-801 (dizocilpine). Operant signal detection was tested using a signal light that varied in intensity (0.027, 0.269, 1.22 lx) of the signal light or in a paradigm which varied the duration (0.5 s, 1 s, 2 s) of the signal light. Both methods of assessing attention showed construct validity for producing gradients of accuracy for signal detection; the dimmest cue led to less accurate responding compared to the brighter cues, and the shortest duration led to less accuracy compared to the longer durations. However, the tests differed in their sensitivity to pharmacological disruption. With the duration test, the high dose of MK-801 along with co-exposure of scopolamine and MK-801 caused a significant reduction of hit and rejection accuracy. Conversely, the intensity variation test did not show significant differences as a function of drug exposures. These data suggest that changes in signal duration, rather than signal intensity, during operant signal detection may have higher sensitivity to detecting drug effects and be a more useful technique for examining pharmacological interventions on attentional behavior and performance