Steroid Administration Research Articles

Orbital Apex Syndrome in a diabetic patient, Is It Tolosa Hunt?

Abstract
 Introduction : The presence of that specific sign in neuro ophthalmology cases can easily determine the differential diagnosis. But the challenge is how do we found the cause. We describe a case of visual loss with ophthalmoplegia in a diabetic patient suspected of having Tolosa Hunt syndrome.
 Case Illustration : Woman, 63 years old with acute visual loss and feel a "heavy eyelid" in the left eye for 2 weeks. The Visual Acuity is no light perception on the left and ophthalmoplegia with mild proptosis. We do the laboratory test and MRI. No specific result of infection was found but the patient was diagnosed with diabetes mellitus (DM) type 2. MRI shows a lesion in the left cavernous sinus. Diagnosis of Orbital Apex syndrome was made. We give the patient a high dose of steroid and then continue with prednisone orally. In 24 hours after treatment the "heavy eyelid" decreased. One month after therapy there are improvements in eye movement but still no light perception.
 Discussion : In cases of orbital apex syndrome with DM, we need to consider mucormycosis as the cause. In this case, the symptoms and signs as well as the MRI led to a Tolosa Hunt. Steroid administration was able to reduce heavy eyelids and cranial nerve palsy even though visual acuity had not improved after 1 month of therapy.
 Conclusion : Laboratory test and Neuroimaging plays an important role to find out the cause. High-dose steroid therapy in a diabetic patient with Tolosa Hunt Syndrome can be given with tight hyperglycemic control.

Ocular complications in pediatric nephrotic syndrome treated with corticosteroids

Background Posterior subcapsular cataracts (PSC) and raised intraocular pressure (IOP) are the most common ocular complications of oral steroid administration, particularly following long-term use or treatment with high doses.
 Objective To evaluate the association between cumulative steroid dose and duration of treatment with the occurrence of PSC and raised IOP, as well as its associated factors in children with idiopatic nephrotic syndrome (INS).
 Methods This cross-sectional study included children aged 4–18 years with INS who received oral steroid therapy for at least six consecutive months. Patients underwent complete eye examinations by an ophthalmologist to evaluate their visual acuity as well as the occurrence of PSC and/or raised IOP. Results Of 92 subjects, 19.6% had PSC, 12% had raised IOP, and one had a best corrected visual acuity (BCVA) of <6/20. The median cumulative steroid dose was 12,161 (range 1,795–81,398) mg and median treatment duration was 23 (range 6–84) months. There were significant positive associations between cumulative steroid dose as well as treatment duration and the occurrence of PSC, with cut-off points of 11,475 mg and 24 months, respectively, as determined by receiver operator characteristic (ROC) curves. Females were four times more likely to have PSC compared to males (PR 4; 95%CI 1.57 to 13.38; P=0.001). Cumulative steroid dose and duration of treatment were not associated with raised IOP.
 Conclusion Cumulative steroid dose of 11,475 mg or higher and/or duration of steroid therapy of 24 months of more were significantly associated with the occurrence of PSC, but not with raised IOP.

Effect of Antenatal Magnesium Sulfate Exposure on Patent Ductus Arteriosus in Premature Infants.

Magnesium sulfate (MgSO4) provides effective fetal neuroprotection. However, there is conflicting evidence regarding the association between antenatal MgSO4 exposure and patent ductus arteriosus (PDA). Thus, herein, we aimed to evaluate the association between antenatal MgSO4 exposure and PDA. Preterm infants born between 240/7 and 316/7 weeks of gestation were included in this retrospective study. Infants who died within the first 72 hours of life and those with significant congenital anomalies were excluded from the study. Echocardiographic and clinical assessment parameters were used to define PDA and hemodynamically significant PDA (hsPDA). Treatments were planned according to the standard protocols of the unit. The following data were collected from hospital medical records: perinatal characteristics, neonatal outcomes, detailed PDA follow-up findings, and maternal characteristics including MgSO4 exposure and doses. Of the 300 included infants, 98 (32.6%) were exposed to antenatal MgSO4. hsPDA rates were similar in the infants exposed and not exposed to antenatal MgSO4, when adjusted for antenatal steroid administration, gestational age, and birth weight (OR: 1.6, 95% CI: 0.849-3.118, p = 0.146). The rates of PDA ligation and open PDA at discharge were similar between the groups. A cumulative MgSO4 dose of >20 g was associated with an increased risk of hsPDA (crude OR: 2.476, 95% CI: 0.893-6.864, p = 0.076; adjusted OR: 3.829, 95% CI: 1.068-13.728, p = 0.039). However, the cumulative dose had no effect on the rates of PDA ligation or open PDA at discharge. Rates of prematurity-related morbidities and mortality were similar between the groups. Although antenatal MgSO4 exposure may increase the incidence of hsPDA, it may not affect the rates of PDA ligation or open PDA at discharge. Further studies are required to better evaluate the dose-dependent outcomes and identify the MgSO4 dose that not only provides neuroprotection but also has the lowest risk of adverse effects. · Antenatal exposure of MgSO4 may cause PDA.. · Antenatal MgSO4 exposure may not increase the rates of PDA ligation or open PDA at discharge.. · Further studies are required to better evaluate the dose-dependent outcomes and optimal MgSO4 dose..

Inflammatory myofibroblastic tumor directly invading the right first rib treated with oral steroids: a case report

BackgroundWe present a case of an inflammatory myofibroblastic tumor cured with a short period of steroid administration, a treatment previously unreported for such cases.Case presentationA 49-year-old man had a chief complaint of chest pain for more than 3 days. Computed tomography (CT) revealed a tumoral lesion suspected to have infiltrated into the right first rib and intercostal muscles, with changes in lung parenchymal density around the lesion. The maximal standardized uptake value on 18 F-fluorodeoxyglucose positron emission tomography/computed tomography was high (16.73), consistent with tumor presence. CT-guided biopsy revealed an inflammatory myofibroblastic tumor with no distant metastases. Surgery was indicated based on the disease course. However, he had received an oral steroid before the preoperative contrast-enhanced CT scan due to a history of bronchial asthma, and subsequent CT showed that the tumor shrank in size after administration; he has been recurrence-free for more than a year.ConclusionsSurgery is still the first choice for inflammatory myofibroblastic tumors, as the disease can metastasize and relapse; however, this condition can also be cured with a short period of steroid therapy.

Surgical intervention ≤ 24 hours versus > 24 hours after injury for the management of acute traumatic central cord syndrome: a systematic review and meta-analysis.

The objective was to evaluate the efficacy, outcomes, and complications of surgical intervention performed within 24 hours (≤ 24 hours) versus after 24 hours (> 24 hours) in managing acute traumatic central cord syndrome (ATCCS). Articles pertinent to the study were retrieved from PubMed, Scopus, Web of Science, and Cochrane. The authors performed a systematic review and meta-analysis of treatment procedures and outcomes according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines. Seven articles comprising 488 patients were included, with 188 (38.5%) patients in the ≤ 24-hour group and 300 (61.5%) in the > 24-hour group. Significant differences were not found between groups in terms of demographic characteristics, injury mechanism, spinal cord compression level, neuroimaging features, and the American Spinal Injury Association (ASIA) motor score at admission. Both groups had a similar approach to surgery and steroid administration. The surgical complication rate was significantly higher in the > 24-hour group (4.5%) compared to the ≤ 24-hour group (1.2%) (p = 0.05). Clinical follow-up duration was similar at 12 months (interquartile range 3-36) for both groups (p > 0.99). The ≤ 24-hour group demonstrated a not statistically significant greater improvement in ASIA motor score, with a mean difference of 12 (95% CI -20.7 to 44.6) compared to the > 24-hour group. The present study indicates potential advantages of early (≤ 24 hours) surgery in ATCCS patients, specifically in terms of lower complication rates. However, further research is needed to confirm these findings and their clinical implications.

Translation of mechanistic advances in preeclampsia to the clinic: Long and winding road.

As one of the leading causes of premature birth and maternal and infant mortality worldwide, preeclampsia remains a major unmet public health challenge. Preeclampsia and related hypertensive disorders of pregnancy are estimated to cause >75 000 maternal and 500 000 infant deaths globally each year. Because of rising rates of risk factors such as obesity, invitro fertilization and advanced maternal age, the incidence of preeclampsia is going up with rates ranging from 5% to 10% of all pregnancies worldwide. A major discovery in the field was the realization that the clinical phenotypes related to preeclampsia, such as hypertension, proteinuria, and other adverse maternal/fetal events, are due to excess circulating soluble fms-like tyrosine kinase-1 (sFlt-1, also referred to as sVEGFR-1). sFlt-1 is an endogenous anti-angiogenic protein that is made by the placenta and acts by neutralizing the pro-angiogenic proteins vascular endothelial growth factor (VEGF) and placental growth factor (PlGF). During the last decade, this work has spawned a new era of molecular diagnostics for early detection of this condition. Antagonizing sFlt-1 either by reducing production or blocking its actions has shown salutary effects in animal models. Further, in early-stage human studies, the therapeutic removal of sFlt-1 from maternal circulation has shown promise in delaying disease progression and improving outcomes. Recently, the FDA approved the first molecular test for preterm preeclampsia (sFlt-1/PlGF ratio) for clinical use in the United States. Measuring serum sFlt-1/PlGF ratio in the acute hospital setting may aid short-term management, particularly regarding step-up or step-down of care, decision to transfer to settings better equipped to manage both the mother and the preterm neonate, appropriate timing of administration of steroids and magnesium sulfate, and in expectant management decisions. The test itself has the potential to save lives. Furthermore, the availability of a molecular test that correlates with adverse outcomes has set the stage for interventional clinical trials testing treatments for this disorder. In this review, we will discuss the role of circulating sFlt-1 and related factors in the pathogenesis of preeclampsia and specifically how this discovery is leading to concrete advances in the care of women with preeclampsia.

Management of sudden sensorineural hearing loss: A time-critical diagnosis.

Sudden sensorineural hearing loss (SSNHL) is an otologic emergency requiring urgent medical attention andcare. This article, based on up-to-date evidence and clinical guidelines, aims to equip general practitioner (GP) specialists with a structured and practical approach to SSNHL management, emphasising the need for prompt evaluation and appropriate interventions. From initial evaluation to treatment strategies and follow-up, this guide offers a step-by-step framework to optimise patient care and improve outcomes in patients suffering SSNHL. Distinguishing SSNHL from conductive hearing loss (CHL), with early identification and prompt initiation of high-dose corticosteroid therapy, are key considerations for the management of SSNHL. Appropriate referrals when indicated for audiometric evaluation, emergency and/or otolaryngology services are also essential. Furthermore, this study aims to outline emerging therapies including intratympanic steroid administration, hyperbaric oxygen therapy and their potential roles in augmenting standard treatment approaches.

The Utilization of Preoperative Steroids Safely Decreases the Risk of Postoperative Delirium in Geriatric Patients After Hip Fracture Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Postoperative delirium is an acute neurocognitive complication that can have adverse effects on outcomes of geriatric patients after undergoing hip fracture surgery. The objective of this study was to examine the efficacy of preoperative steroids in preventing postoperative delirium after hip fracture surgery. A systematic review and meta-analysis was performed using PubMed, SPORTDiscus, CINAHL, MEDLINE, and Web of Science from database inception until September 28, 2023. Inclusion criteria were randomized controlled trials of patients who underwent surgical intervention for hip fracture, were examined for postoperative delirium, and used preoperative steroids. Data included the risk of postoperative delirium, postoperative all-cause infection, and postoperative hyperglycemia. Articles were graded via the Cochrane Collaboration's tool. Statistical analysis included a random-effects binary model with relative risk, 95% confidence intervals along with a defined "number needed to treat" threshold (number needed to treat). Four randomized controlled trials were included from 128 articles initially retrieved. Patients (n = 416; average age: 82.2 ± 2.2 years) underwent surgical intervention for hip fracture after receiving either preoperative steroids (n = 209) or control interventions (n = 207). There was a statistically significant decrease in the incidence of postoperative delirium among patients who received preoperative steroids (12.9%; 27 cases) as compared with patients who received control interventions (26.7%; 55 cases) after hip fracture surgery ( P < 0.001; RR: 0.84). The absolute risk difference was 13.8%, and the number needed to treat was 7.2 patients. There was no statistically significant difference in the risk of postoperative all-cause infection among patients who received preoperative steroids as compared with patients who received normal saline as placebo after hip fracture surgery ( P = 0.850; RR: 0.96). The utilization of preoperative steroids seems to decrease the risk of postoperative delirium after hip fracture surgery in elderly adults. Furthermore, this decreased risk of postoperative delirium was not associated with a significant increase in postoperative infection, indicating possible safety of preoperative steroid administration. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Association between the Duration of Steroid Therapy with Hyperglycemia in Patients with Systemic Lupus Erythematosus (SLE)

Introduction: Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease which primary treatment consists of steroid drugs administration. Prolonged steroid administration is often associated with an increase in blood glucose, a condition known as hyperglycemia. Hence, this study aimed to evaluate the association between the duration of steroid therapy with hyperglycemia in patients with SLE treated at a tertiary healthcare center in Surabaya, Indonesia.Methods: A cross-sectional study was conducted under a purposive sampling frame from January to December of 2022 by utilizing secondary data from electronic medical health records in Dr. Soetomo General Academic Hospital, a tertiary healthcare center in Surabaya, Indonesia. The association between variables were analyzed using Fisher’s exact test, chi square test, independent T-test, one-way ANOVA, Mann-Whitney, and Spearman's rank correlation.Results: Out of 150 included patients, 2.67% experienced hyperglycemia following steroid therapy for SLE. There were no significant associations between clinical variables and hyperglycemia occurence in SLE patients (p&gt;0.05). Patients that received higher doses of steroid did not experience any significant difference in hyperglycemia (p=0.727 for &lt;6 months; p=0.865 for ≥6 months). Daily steroid dose was also not significantly associated with the severity of SLE manifestations based on the SLEDAI score (p=0.081). Overall, no significant association was identified between the duration of steroid therapy with hyperglycemia among SLE patients in the hospital (p=0.365). Conclusion: The study found no significant correlation between clinical variables, hyperglycemia incidence, daily steroids dosage, methylprednisolone dosage, SLE severity, or steroid use duration in patients with Systemic Lupus Erythematosus.

Relapse and side effects of steroid therapy beyond 3 years in autoimmune pancreatitis: A multicenter retrospective study

BackgroundThe impact of extended steroid administration on patients with autoimmune pancreatitis after a 3-year maintenance period remains poorly understood. This study analyzed the advantage and disadvantage of continuing steroid therapy beyond 3 years. MethodsIn this retrospective multicenter study across 17 institutions, patients who successfully completed 3 years of maintenance therapy without experiencing relapse were categorized into two groups: the maintenance therapy discontinuation group, who discontinued steroid therapy after the initial 3-year period, and maintenance therapy continuation group, who continued steroid therapy beyond 3 years. The cumulative relapse rate after 3 years of maintenance therapy was the primary outcome. Relapse predictors were compared using the Gray test for cumulative relapse incidence by specific factor. ResultsOf 211 patients, 105 experienced no relapse during the 3-year maintenance therapy and were divided into two groups: 69 in the maintenance therapy discontinuation group and 36 in the maintenance therapy continuation group. The relapse rate was lower in the maintenance therapy continuation group than in the maintenance therapy discontinuation group (P = 0.035). Predictors of relapse after 3 years included cessation of maintenance therapy (hazard ratio [HR] = 3.76; 95 % confidence interval [CI] = 1.07–13.3, P = 0.040) and renal involvement (HR = 2.88; 95 % CI = 1.04–7.99, P = 0.042). The maintenance therapy continuation group showed a significantly higher prevalence of macrovascular complications, compared with the maintenance therapy discontinuation group (P = 0.005). ConclusionsCessation of steroid maintenance therapy and renal involvement were predictors of relapse after 3 years of maintenance therapy. However, the long-term use of steroids may increase the risk of macrovascular complications.

Predictive factors for esophageal stenosis in patients receiving prophylactic steroid therapy after endoscopic submucosal dissection for esophageal squamous cell carcinoma.

Methods to prevent esophageal stenosis (ES) after endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (ESCC) have received increasing attention. Although steroid administration is a prophylactic treatment, the risk factors for ES during prophylactic steroid therapy remain unknown. Therefore, this study aimed to retrospectively evaluate the risk factors for refractory ES in patients administered prophylactic steroids after ESD for ESCC. Among 795 patients with ESCC (854 lesions), 180 patients (211 lesions) administered local triamcinolone acetonide (TrA) and/or oral prednisolone were recruited for this study. We compared the total number of endoscopic balloon dilatation (EBD) procedures performed for post-ESD ES and clinical findings (tumor size, ESD history or chemoradiation therapy [CRT], entire circumferential resection, muscle layer damage, supplemental oral prednisolone administration, EBD with TrA injection, and additional CRT) between patients with refractory and non-refractory ES. EBD was continued until dysphagia resolved. We categorized cases requiring ≥ 8 EBD procedures as refractory postoperative stenosis and divided the lesions into two groups. Multivariate logistic regression analysis revealed that factors such as ESD history, CRT history, tumor size, and entire circumferential resection were independently associated with the development of refractory ES. The withdrawal rates of EBD at 3years were 96.1% (52/53) and 58.5% (39/59) in the non-refractory and refractory groups, respectively. Our data suggest that entire circumferential resection and CRT history are risk factors for refractory post-ESD ES in ESCC, even with prophylactic steroid administration.

A Retrospective Analysis of Incidence and Risk Factors for the Development of Secondary Infections Following COVID-19

Abstract Introduction The SARS-CoV-2 virus primarily affects the lungs causing a heightened immune response due to viral and host cell interaction, which prompts the release of proinflammatory cytokines and reduces the defense mechanisms of the immune system, making the patient vulnerable to secondary infections. The study aims to identify the incidence and risk factors for secondary infections developing after COVID-19. Methods and Materials A retrospective study was conducted on 669 patients who were readmitted after COVID-19 to a tertiary care hospital. The development of secondary infections in these populations was identified. The data were collected from the medical records department. Statistical Analysis Incidence was calculated by the ratio of the total number of patients who developed secondary infections among readmitted patients divided by the total number of readmitted patients during the study period. Univariate analysis was performed to identify the statistically significant variables that were used in logistic regression for identifying the risk factors for secondary infection. Statistical analysis was performed in SPSS version 28.0. Results and Discussion In this study, 85 patients were found to have developed secondary infections with an incidence of 12.7%. Among the reported six infections, mucormycosis showed the highest incidence (34.1%), followed by sepsis and urinary tract infection. Nine patients developed tuberculosis as a post-COVID-19 secondary infection. General risk factors for secondary infections include male gender, presence of comorbidities such as diabetes mellitus and chronic kidney disease (CKD), intensive care unit (ICU) admission, elevated levels of interleukin-6 (IL-6) and D-dimer, and administration of steroids particularly medium-dose steroids. Conclusion Secondary infections can occur within 43 days of COVID-19 infection for every 12.7 per 100 patients in whom there is bacterial or fungal infections. Of these secondary infections, incidence of mucormycosis and sepsis was found to be higher in our study. COVID-19-infected patients who have either of these factors such as elevated inflammatory markers (Il-6 and D-dimer), the presence of comorbidities such as diabetes mellitus and CKD, ICU admission, and the use of steroids are at risk of developing secondary infections. Through proper screening, we can prevent patients who are at risk of developing secondary infections.

Nephrotic syndrome due to focal segmental glomerulosclerosis complicating scleroderma: a case report

BackgroundSystemic scleroderma (SSc) is an insidious autoimmune connective tissue disorder with multiorgan involvement. Renal involvement is one of the important causes of morbidity and mortality in scleroderma; however, nephrotic syndrome is reported rarely in association with SSc. We present a patient with SSc who developed focal segmental glomerulosclerosis (FSGS) as a complication of scleroderma.Case presentationA 59 year old Caucasian female patient, with a known history of diffuse systemic sclerosis from 8 years, presented to our clinic with symptoms of anasarca and weight gain. Her physical examination was unremarkable except for periorbital and extremity edema. Her biochemistry assessment revealed decreased serum albumin levels and elevated serum creatinine levels. A renal biopsy was performed, which showed histopathological patterns of FSGS type of nephrotic syndrome. After administration of high doses of steroid and rituximab in the course of her treatment for 6 months, her symptoms and proteinuria were improved without the occurrence of scleroderma renal crises.ConclusionSSc is a complex multisystemic autoimmune disorder. SRC is the most prominent renal involvement in SSc, but other renal pathologies may also occur. Each patient should be precisely investigated since managing these renal conditions can differ significantly. Nephrotic syndrome is a rare complication of SSc, which could be managed with prompt diagnosis and steroid administration.

Clinical Characteristics, Treatment, and Prognosis of Amoxicillin-Induced AGEP/ALEP

Background. Amoxicillin was associated with acute generalized exanthematous pustulosis (AGEP), and the clinical characteristics were not clear. The purpose of this study was to explore the clinical characteristics of amoxicillin-induced AGEP and to provide a basis for prevention and treatment. Methods. Case reports and case series of amoxicillin-induced AGEP were collected for retrospective analysis by searching the Chinese and English databases from inception to January 31, 2023. Results. A total of 46 patients were included with a median age of 40 years (range 1.4, 87). The onset time of AGEP ranged from 6 hours to 28 days, with a median of 2.5 days. Fever occurred in 32 patients (69.6%), and pruritus occurred in 13 patients (28.3%). Ten patients (21.7%) had mucous membrane involvement and systemic involvement, respectively. Twenty-two patients had elevated neutrophils, with a median of 12850/mm3 (range 7880, 29140). Skin biopsy mainly showed subcorneal pustules (22 cases, 47.8%), spongy pustules (14 cases, 30.4%), and inflammatory cell infiltration (26 cases, 56.5%). Skin lesions disappeared in a median of 10 days (range 2, 42) after discontinuation of amoxicillin and administration of topical steroids (26 cases, 56.5%) as well as systemic corticosteroids (13 cases, 28.3%). Conclusions. AGEP is a rare complication of amoxicillin and is self-limiting. Clinicians should correctly identify AGEP and should avoid represcribing amoxicillin. Clinicians should correctly identify AGEP and avoid represcribing amoxicillin, which can prevent unnecessary treatment measures.

Preterm Birth and in Utero Exposure to Corticosteroids Are Associated With Increased Infection Risk in Children of Mothers With IBD.

Corticosteroids, thiopurines, and biologics may come into play during pregnancy in women with inflammatory bowel disease and potentially impact the developing fetal immune system. We aimed to assess the risk of serious infections in children stratified by in utero exposure to biologics and immunomodulators or concomitant treatment with corticosteroids. All singleton IBD pregnancies between 2008 and 2022 at a tertiary IBD center in Denmark were included. Maternal and offspring demographics, maternal disease activity, antenatal medical treatment, and infant infections resulting in hospital admission were recorded after review of medical records. In 602 live births (99.0%), we registered exposure to antenatal treatment as follows: biological monotherapy (n = 61, 10.2%), thiopurines (n = 110, 17.9%), biologics and concomitant thiopurines (n = 63, 10.3%), and controls (ie, no treatment with biological and/or thiopurines; n = 369, 60.6%). Preterm delivery (<37 gestational weeks) and systemic steroid administration during the third trimester were associated with an increased risk of serious infection in the offspring immediately after birth (relative risk = 17.5; 95% confidence interval, 7.8-39.8; P < .001, and relative risk = 4.8; 95% confidence interval, 1.5-12.7; P = 0.003, respectively).Intra-uterine exposure to biologics or combination treatment were not associated with a statistically significant higher risk of serious infections compared with controls; however, combination treatment showed an inclination towards an increased risk across analyses. Preterm birth and systemic corticosteroid administration late in pregnancy are significant risk factors for serious infections in the offspring of IBD mothers.

Effect of fasedienol (PH94B) pherine nasal spray and steroidal hormones on electrogram responses and autonomic nervous system activity in healthy adult volunteers.

Fasedienol (PH94B) is a pherine compound formulated as a nasal spray that is hypothesized to regulate olfactory-amygdala circuits of fear and anxiety. Fasedienol's effect on the local electrogram of nasal chemosensory neurons (EGNR) and autonomic nervous system (ANS) responses versus steroidal hormones and controls in healthy adults is reported. Eight males and 8 females randomly received aerosolized control (propylene glycol) and study drugs (fasedienol, 17β-estradiol, progesterone, cortisol, and testosterone, 0.4μg each in propylene glycol) onto the nasal septum mucosal lining at 30-min intervals over 2 sessions. EGNR was continuously monitored; autonomic parameters were recorded before and after administration. Fasedienol significantly increased EGNR amplitude (males: 5.0 vs. 0.6mV, p<0.001; females:5.7 vs. 0.6mV, p<0.001), and rapidly reduced respiratory rate (p<0.05), heart rate (p<0.01), and electrodermal activity (p<0.05) versus control. EGNR and ANS responses after steroidal hormone administration were similar to control. 81% reported feeling less tense/more relaxed after receiving fasedienol, but not after receiving either control or steroidal hormones. Intranasal fasedienol, but not control or steroidal hormones, activated EGNR and rapidly reduced ANS responses, consistent with sympatholytic effects. Combined with subjective reports, results suggest fasedienol may provide acute relief in anxiety conditions.

Regional Variation in Antenatal Late Preterm Steroid Use Following the ALPS Trial

The publication of the Antenatal Late Preterm Steroids (ALPS) trial in February 2016 demonstrated that antenatal administration of betamethasone in the late preterm period (between 34 to 36 weeks of gestation) for individuals with a high risk of delivery decreased neonatal respiratory morbidity. National estimates have suggested the trial did change obstetric practice, but little is known if the evidence was adopted uniformly or equitably. To assess regional variation in the use of late preterm steroids after the publication of the Antenatal Late Preterm Steroids (ALPS) Trial and to understand factors associated with a region's pace of adoption. This cross-sectional study used US natality data from February 2015 to October 2017 from hospital referral regions (HRRs) within the US. Inclusion criteria included live-born, nonanomalous, singleton, late preterm (34 to 36 completed weeks of gestation) neonates born to individuals without pregestational diabetes. This study was conducted from November 15, 2022, to January 13, 2023. HRRs were categorized as either a slower adopter or faster adopter of antenatal late preterm steroids based on the observed vs expected pace of antenatal steroid adoption in a 1-year period after the trial's dissemination. Patient and regional factors hypothesized a priori to be associated with the uptake of late preterm steroids were compared between faster and slower adopters. Comparisons were made using Student t test or Wilcoxon rank-sum test, as appropriate. A multivariable logistic regression was constructed to identify factors associated with faster adopter status in the postperiod. There were 666 097 late preterm births in 282 HRRs. The mean (SD) maternal age in HRRs was 27.9 (1.2) years. The median (IQR) percentage of births by race categories in HRRs for patients identifying as American Indian or Alaskan Native was 0.5% (0.2%-1.3%); Asian or Pacific Islander, 3.0% (1.7%-5.3%); Black, 12.9% (5.1%-29.1%); and White, 78.6% (66.6%-87.0%). The median percentage of births in HRRs to patients of Hispanic ethnicity was 11.2% (6.3%-27.4%). In this study, 136 HRRs (48.2%) were classified as faster adopters and 146 (51.8%) were classified as slower adopters. Faster adopters increased their steroid use by 12.1 percentage points (from 5.9% to 18.0%) compared with a 5.5 percentage point increase (from 3.7% to 9.2%) among slower adopters (P < .001). Most examined patient and regional factors were not associated with a region's pace of adoption, with the exception of the regional prevalence of prior preterm birth (adjusted odds ratio [aOR], 2.04 [95% CI, 1.48-2.82]) and the percentage of deliveries at 34 to 35 weeks of gestation (aOR, 0.68 [95% CI, 0.47-0.99]) compared with 36 weeks. In this cross-sectional study, there was widespread geographic variation in the adoption of antenatal steroid administration for late preterm births that largely remained unexplained by population factors. These findings should prompt further investigations to barriers to timely or equitable access to new evidence-based practices and guide future dissemination strategies with the goal of more uniform adoption.

The Effects of Preoperative Epidural Steroid Injection on Pseudarthrosis Following Lumbar Fusion: A Retrospective Cohort Study.

Retrospective cohort study. The goal of this study is to evaluate the effects of preoperative lumbar epidural steroid injection on the rate of pseudarthrosis following lumbar spine fusion surgery. Epidural corticosteroids help to reduce nerve root edema and suppress proinflammatory cytokines in patients with radiculopathy. Corticosteroids may inhibit bone formation and reduce bone matrix synthesis rates. Thus, there is concern that corticosteroids may reduce lumbar fusion capability, potentially resulting in increased rates of symptomatic pseudarthrosis. We identified all patients who underwent 1-level or 2-level lumbar fusion surgery between 2018 and 2022. Patients were categorized into one of 3 groups: no preoperative epidural steroid injection (ESI) history (group 0), preoperative ESI within 90 days of surgery (group 1), or most recent ESI >90 days before surgery (group 2). The primary outcome of this study was pseudarthrosis. Binominal regression analyses were performed to determine the relationships between potential risk factors (sex, age, body mass index, smoking history, diabetes status, history of systemic steroid use, preoperative ESI, perioperative intravenous steroid administration, type of surgery, and postoperative ESI within 6mo) and the development of postoperative pseudarthrosis. A total of 446 patients were included in this study. Of those, 106 patients (23.7%) did not have a preoperative ESI (group 0), 132 patients (29.5%) had an ESI within 90 days of surgery (group 1), and 208 patients (46.6%) had their most recent ESI >90 days before surgery (group 2). The overall incidence of pseudarthrosis following lumbar fusion was 8.7% (39 of 446). Although the incidence of pseudarthrosis following ESI at any time point was higher than in our control cohort (group 0), this difference was not statistically significant. This study found no increased risk of postoperative pseudarthrosis in patients who underwent 1-level or 2-level lumbar fusions after preoperative ESI. Level III.

A review of epidural and non-epidural contrast flow patterns during fluoroscopic and CT-guided epidural steroid injections.

Epidural steroid injections are commonly performed using fluoroscopic or CT guidance. With both modalities, the injection of contrast material is necessary before steroid administration to ensure adequate epidural flow and exclude non-epidural flow. While fluoroscopic guidance is conventional, CT is utilized at some centers and can be particularly helpful in the setting of challenging or postoperative anatomy. It is important for proceduralists to be adept at evaluating contrast media flow patterns under both modalities. The goal of this review article is to describe and provide examples of epidural and non-epidural flow patterns on both conventional fluoroscopy and CT. Specific non-epidural patterns discussed include intrathecal flow, intradural/subdural flow, vascular uptake, flow into the retrodural space of Okada, inadvertent facet joint flow, and intradiscal flow.

Efficacy of nivolumab in combination with chemotherapy after radiotherapy for meningeal carcinomatosis in patients with Epstein-Barr virus-associated gastric cancer:a case report

A 62-year-old man presented with fever and anorexia since July X. Initial treatments were rendered ineffective, and due to altered consciousness and vomiting, he was referred to our hospital. On admission, he manifested delirium, drowsiness, and disorientation. While blood tests were normal, gastroscopy identified a type 3 tumor in his lower gastric body, later diagnosed as a poorly differentiated adenocarcinoma. Immunohistochemistry demonstrated negative human epidermal growth factor receptor 2 and positive programmed death-ligand 1 expression with a combined positive score ≥5. Furthermore, a positive Epstein-Barr virus-encoded small RNA in situ hybridization result was noted. Abdominal contrast-enhanced CT and PET-CT scans demonstrated multiple lymph node metastases around the stomach and liver, establishing the diagnosis of stage IVB gastric cancer (T4aN2M1). Brain magnetic resonance imaging (MRI) demonstrated enhanced lesions in the brainstem, cerebellar sulci, and right occipital lobe. Although cerebrospinal fluid cytology was negative for malignancy, the clinical symptoms and MRI findings confirmed leptomeningeal carcinomatosis (LMC). The patient underwent radiotherapy for LMC (total of 30Gy in 10 fractions), followed by combination therapy with a nivolumab and SOX regimen. Posttreatment, the LMC symptoms resolved;however, he experienced grade 3 immune-related adverse events related to liver dysfunction. Nivolumab was discontinued, and with steroid administration, the adverse events improved. Imaging evaluations posttreatment showed gastric tumor reduction and the absence of LMC. After 7 cycles, nivolumab was reintroduced, with no liver dysfunction recurrence noted through 15 cycles. Endoscopic examination 1 year postonset demonstrated that the gastric tumor had scarred, and MRI showed no signs of LMC recurrence. In 5-8% of solid tumors, LMC complications are present, resulting in limited treatment options and poor prognosis. Recent reports suggest the potential of immune checkpoint inhibitors in treating intracranial metastasis from solid tumors. In Japan, nivolumab was approved for gastric cancer treatment in 2017 and for first-line therapy in combination with chemotherapy since 2021. We report a case in which radiotherapy and chemotherapy combined with nivolumab provided durable control of LMC originating from gastric cancer for more than 1 year.