Uncomplicated Clinical Course Research Articles

Clinical and Financial Validation of the International Study Group for Pancreatic Surgery (ISGPS) Definition of Post-Pancreatectomy Acute Pancreatitis (PPAP): International Multicenter Prospective Study.

To validate the ISGPS definition and grading system of PPAP after pancreatoduodenectomy (PD). In 2022, the International Study Group for Pancreatic Surgery (ISGPS) defined post-pancreatectomy acute pancreatitis (PPAP) and recommended a prospective validation of its diagnostic criteria and grading system. This was a prospective, international, multicenter study including patients undergoing PD at 17 referral pancreatic centers across Europe, Asia, Oceania, and the United States. PPAP diagnosis required the following three parameters: (1) postoperative serum hyperamylasemia /hyperlipasemia (POH) persisting on postoperative days 1 and 2, (2) radiologic alterations consistent with PPAP, and (3) a clinically relevant deterioration in the patient's condition. To validate the grading system, clinical and economic parameters were analyzed across all grades. Among 2902 patients undergoing PD, 7.5% (n=218) developed PPAP (6.3% grade B and 1.2% grade C). POH occurred in 24.1% of patients. Hospital stay was associated with PPAP grades (No POH/PPAP 10 days (IQR 7-17) days, grade B 22 days (IQR 15-34) days, and grade C 43 days (IQR 27-54) days; P<0.001), as well as intensive care unit admission (No POH/PPAP 5.4%, grade B 12.6%, grade C 82.9%; P<0.010), and hospital readmission rates (No POH/PPAP 7.3%, grade B 16.1%, grade C 18.5%; P<0.05). Costs of grade B and C PPAP were 2 and 11 times greater than uncomplicated clinical course, resp. (P<0.001). This first prospective, international validation study of the ISGPS definition and grading system for PPAP highlighted the relevant clinical and financial implications of this condition. These results stress the importance of routine screening for PPAP in patients undergoing PD.

Clinical Examples of the Additive Value of Absolute Quantification of Cell-Free DNA After Heart Transplantation.

Cell-free DNA (cfDNA) is used as a biomarker after transplantation to detect graft injury, relying on the donor fraction (DF). We have established a PCR-based approach allowing us to separately quantify absolute values of dd-cfDNA and recipient-derived cfDNA (rd-cfDNA). We aimed to present typical clinical scenarios after heart transplantation (HTx) to illustrate the advantages of absolute cfDNA values over DF. We used the cfDNA results of our cohort (509 samples of 52 patients followed during the first year after HTx) as background and determined the trajectories of cfDNA in specific clinical situations. We profiled an uncomplicated clinical course, viral and bacterial infections, acute and chronic rejection, and false-negative and false-positive rejections in six patients (five adults, one child). There was a substantial discrepancy between relative (DF) and absolute cfDNA-levels in several clinical situations. Rd- and dd-cfDNA were independently elevated during episodes of rejection and infection and were better suited to depict treatment response than DF alone. Absolute quantification of cfDNA may offer clinically relevant information additive to DF in various situations after HTx and could be helpful for more accurate monitoring of diagnosis and treatment of rejection.

Biomarkers and Biochemical Indicators to Evaluate Bone Metabolism in Preterm Neonates.

The purpose of the present study was to evaluate the concentrations of some bone turnover markers in preterm neonates with uncomplicated clinical course in the first month of life. Samples from 13 preterm neonates were collected at three different times: at birth (T0) from umbilical cord blood (UCB); and at 15 (T1) and 30 (T2) days of life from peripheral blood (PB). The concentrations of calcium (Ca), phosphate (P), total alkaline phosphatase (ALP), Collagen Type 1 Amino-terminal Propeptide (PINP), osteocalcin (OC), Collagen Type 1 Carboxyl-Terminal Telopeptide (CTX) and Leptin were assessed. A statistically significant difference for ALP concentration at birth versus T1 and T2 was found. An evident increase in the median concentrations of CTX, OC and PINP from T0 to T2 were observed. A significant difference was also found for Leptin concentration at T0 compared to T1. In preterm infants, in the absence of acute or chronic medical conditions and without risk factors for metabolic bone disease (MBD) of prematurity, there is a significant increase in bone turnover markers during the first month of life. The knowledge of the variations in these markers in the first weeks of life, integrated by the variations in the biochemical indicators of bone metabolism, could help in recognizing any conditions at risk of developing bone diseases.

Cardiac and Neurological Complications Post COVID-19 Vaccination: A Systematic Review of Case Reports and Case Series.

Following mass vaccinations for the control of the COVID-19 epidemic, a spectrum of cardiac and neurological disorders was reported among vaccinated individuals. This study examined the range of complications documented and factors related to their occurrence. Three electronic databases were searched for case reports and case series with descriptions of cardiac and/or neurological complications in COVID-19 vaccine recipients. A total of 698 vaccinees were included in this review, of which 259 (37.1%) had cardiac and 439 (62.9%) had neurological complications. Inflammatory conditions were the commonest among the cardiac complications; while polyneuropathy, demyelinating diseases and cerebrovascular disorders were the more common neurological complications. The mean age of those with cardiac complications (33.8 years) was much younger than those with neurological complications (49.7 years). There was no notable difference in the gender distribution between these two groups of vaccine recipients. mRNA vaccines (all brands) were associated with almost 90.0% of the cardiac complications, whereas viral vector vaccines were associated with slightly over half (52.6%) of the neurological complications. With regard to the dose, cardiac complications were more common after the second (69.1%), whereas neurological complications were more common after the first dose (63.6%). The majority of the cases had an uncomplicated clinical course. Nevertheless, 5.9% of cases with neurological complications and 2.5% of those with cardiac complications were fatal, underscoring the significance of the consistent surveillance and vigilant monitoring of vaccinated individuals to mitigate these occurrences.

Huge mediastinal ancient schwannoma causing acute respiratory failure: a case report

Benign mediastinal tumor is usually asymptomatic and exhibits uncomplicated clinical course. Posterior mediastinal schwannoma is common, but a huge benign tumor causing acute respiratory failure due to mass effect is unusual. We present a patient who suffered from acute respiratory failure due to huge mediastinal mass effect and improved after en bloc surgical resection. A 56-year-old woman had no history of systemic disease, but experienced general discomfort and malaise for several months. She was referred to our emergency department after developing sudden respiratory failure. Intubation was performed with ventilator support and she was admitted to the intensive care unit. Chest radiograph and computed tomography showed a huge mass over the left pleural cavity causing left lung, heart, and mediastinal compression. After en bloc resection, she was weaned off the ventilator successfully and was discharged at 24 days after the operation. Postoperative outpatient follow-up showed no symptoms. Mediastinal ancient schwannoma is a rare posterior mediastinal benign tumor. However, mass effect might lead to lethal complications. En bloc resection is necessary for curative treatment.

Heterogeneous Genetic Landscape of Chronic Idiopathic Neutropenia Revealed By Whole Exome Sequencing

Background: Adultpatients with persistent, unexplained neutropenia who do not fulfill the diagnostic criteria of any underlying disease are characterized as chronic idiopathic neutropenia (CIN) cases.It is an exclusion diagnosis that can be established after a thorough clinical/laboratory investigation for any underlying causes, including negative anti-neutrophil antibody testing, inconclusive bone marrow (BM) aspiration/biopsy and normal cytogenetics. CIN patients regardless of their absolute neutrophil counts (ANC) usually display a benign and uncomplicated clinical course. Although the pathogenesis of CIN remains largely unknown, we hypothesize that a constitutional/congenital background might exist, at least in some cases, that have potentially escaped diagnosis during childhood. Aim of the study: To investigate the genetic landscape of neutropenia in CIN by conducting whole exome sequencing (WES) analysis in a number of adult CIN patients. Methods: We have performed WES in 16 adult (median age 59 years, range 30-72 years) patients (11 females and 5 males) with CIN according to previously published criteria (Fioredda F, et al Hemasphere. 2023). The patients had median ANC 1.2 x 10 9/L (range 0.4-1.6 x 10 9/L) for prolonged period and unknown neutropenia onset in most cases. Genomic DNA was extracted from peripheral blood samples, coding fragment libraries were prepared, sequencing performed on Illumina NovaSeq 6000 System, and data subjected to an in-house pipeline for bioinformatic analysis for variant calling and annotations. Singleton analyses were performed focusing on genes associated with congenital defects of phagocytes, BM failure (BMF) and immune deficiency and dysregulation. Mean depth of coverage was 70x and the mean number of variants/sample was 22553. Results: WES analysis identified 10 pathogenic/likely pathogenic (P/LP) variants in 10 patients. The variants consisted of 4 frameshift mutations, 3 nonsense mutations, 1 missense mutation, 1 splice-site mutation and 1 splice-region mutation. Pathogenic variants in congenital neutropenia (CN)-related genes included only a heterozygous mutation in G6PC3:c.511C&amp;gt;T,p.Gln171Ter (previously detected in one of our CN patients; Nikolouzakis TK et al, Ann Hematol. 2022). Pathogenic variants in genes associated with BMF were detected in two genes, namely FANCM:c.1492C&amp;gt;T, p.Gln498Ter and CTC1:c.3058C&amp;gt;T,p.Gln1020Ter, respectively. The majority of the pathogenic variants were found in genes associated with immune deficiency and dysregulation. These involved: (i) a heterozygous mutation in DCLRE1C:c.1784dup,p.Ile596fs (associated with immunodeficiencies affecting cellular and humoral immunity); (ii) a LP mutation in ORAI1:c.132_133del,p. Arg45fs and a pathogenic variant in SPINK5:c.1302+4A&amp;gt;T (related to combined immunodeficiencies with associated or syndromic features); (iii) a pathogenic variant in MEFV:c.2080A&amp;gt;G, p.Met694Val and a LP variant in PSMG2:c.703-2A&amp;gt;T (both genes associated with autoinflammatory disorders); (iv) a LP variant in IRF7:c.1089dup,p.Pro364Alafs (associated with defects in intrinsic and innate immunity); and (v) a LP variant in PEPD:c.738_739insGT,p.Ser247fs (associated with immune dysregulation). Regarding variants of undetermined significance (VUS) an average of 4.5 VUS variants per patient were detected in genes related to CN ( HAX1, VPS13B, LYST), BMF ( GATA2, SAMD9, CXCR4) or immunodeficiency ( TCF3). However, none of these patients display clinical symptoms typical of these conditions. Specifically, the majority of the patients presented with mild/moderate neutropenia and rarely with severe neutropenia, they have relatively normal BM biopsies and do not display major symptoms or signs related to severe immunodeficiency or immune dysregulation syndromes. Conclusions: This study is the first attempt of WES analysis in adult CIN patients and shows that there is a heterogeneous genetic landscape underlying the disease. More studies are required so that the detected P/LP variants and VUS can be associated with the clinical phenotypes to more accurately interpret their potential contribution to the neutropenia phenotype.

Neurodevelopmental Outcomes in Preterm Babies: A 12-Month Observational Study.

Background Preterm births are a significant concern worldwide due to their association with both short- and long-term morbidity. Modern neonatal intensive care techniques have improved the survival of infants born at the brink of viability. However, there remain significant challenges concerning their neurodevelopment. A considerable proportion of very low birth weight infants exhibit significant motor deficits such as cerebral palsy or cognitive, behavioral, or attention disabilities. The consequences of these impairments, particularly given their life-long nature, can be severe for the affected individuals, families, and public health resources. Consequently, timely neurodevelopmental assessment is critical in recognizing delayed development and selecting infants for neurodevelopmental stimulation. This study aimed to estimate the neurodevelopment of preterm infants, identify influencing factors, detect at-risk groups, and refer/recommend early intervention when developmental delays are observed. Methodology This prospective, observational, hospital-based study done in the department of pediatrics, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Gotri, Vadodara, Gujrat, India included inborn and outborn preterm neonates admitted to the Neonatal Intensive Care Unit (NICU) or the Sick Newborn Care Unit from their first day of life. The study period was from October 2020 to January 2021, and only neonates with an uncomplicated clinical course were included. Newborns were enrolled in a high-risk clinic, and follow-up appointments were scheduled at three, six, nine, and 12 months of corrected gestational age (CGA). We used the Baroda Developmental Screening Tool (BDST) to calculate the developmental quotient (DQ) at each appointment. This assessment involved parental interviews, observation of developmental milestones, and simple test demonstrations. The gathered DQ data at different ages were analyzed and compared across groups. Results Of 100 preterms enrolled, 62 preterms were followed up until 12 months of CGA. Thirteen patients out of the 62(approximately one-fifth) preterm neonates exhibited developmental delays at one year of CGA, most of whom were early preterm infants. Twenty-six patients (approximatelytwo-fifths) were delayed at three months of CGA, and thus 13 patients (half) showed catch-up growth and development. There was no statistically significant difference between the neurodevelopment of female and male infants. However, infants born to mothers with better socioeconomic status and higher education showed improved neurodevelopment. Conclusions Our study findings suggest that preterm infants discharged from the NICU exhibit poor neurodevelopmental outcomes, especially those born early preterm. This pattern indicates an inverse relationship between neurodevelopmental delay and the maturity of the neonate. Maternal education and socioeconomic status positively impacted the neurodevelopment of preterm NICU graduates. Thus, regularfollow-up (at least once every three months), early detection by a screening scale like the BDSTand intervention significantly improved neurodevelopmental outcomes.

Simultaneous Cardiocerebral Infarction Associated with Postcoital Activity

BackgroundCardiocerebral infarction (CCI) is a rare and life-threatening presentation of simultaneous acute myocardial infarction and acute ischemic stroke that requires prompt recognition and proper treatment. CCI is time sensitive and carries a high mortality rate. There is no standardized treatment algorithm that addresses both conditions simultaneously. Case ReportWe present a 29-year-old man with simultaneous myocardial infarction and thrombotic stroke after coital activity. He presented to the Emergency Department with left-sided extremity weakness and numbness and radicular left-sided chest pain. He suffered a cardiac arrest during his evaluation and required emergent percutaneous coronary intervention with stent placement. He was resuscitated successfully and had an uncomplicated clinical course, with improved neurologic recovery prior to discharge. Why Should an Emergency Physician Be Aware of This?CCI is a rare condition that typically occurs in elderly patients with risk factors for cardiovascular disease. Management is challenging due to the time-sensitive nature of diagnosis and treatment of each condition. Treatment is not standardized, unlike individual evidence-based algorithms for thrombotic stroke and acute myocardial infarction. Risks and benefits for each treatment plan should be weighed and therapy should be directed toward the most immediate life-threatening process. This case would add to the literature surrounding this condition and help guide emergency physicians toward the most optimal treatment strategies for this patient population. This case also raises awareness of the existence of this condition and its potential presence in young, otherwise healthy patients.

Retrograde Intramedullary Antibiotic Impregnated Cement Nailing for Treatment of Infected Primary Tibiotalocalcaneal Arthrodesis

The management of infected primary tibiotalocalcaneal arthrodesis (TTCA) is a daunting task for foot and ankle surgeons. For the last 2 decades, antibiotic bone cement nails have become a method to treat intramedullary infections, such as those seen in infected TTCA, as they provide the dual benefits of eluting high amounts of antibiotics into medullary canal while providing some stability to the bone. Studies have demonstrated the effectiveness of this salvage technique in treating infected primary TTCA. Because of the lack of commercially available antibiotic impregnated nails for this procedure, there is significant variation in techniques utilized. In addition, the rarity of these cases can make execution of this technique difficult and time consuming. To date there is no comprehensive technique guide for this procedure. We present a detailed photographic record and technical details of a modified technique for employing an antibiotic spacer nail for a 64-year-old female patient undergoing revision TTCA. The patient had an uncomplicated postoperative clinical course with no evidence of wound infection. Her osteomyelitis subsequently resolved, and she was able to ambulate with minimal pain with a Charcot Restraint Orthotic Walker. Surgeons can utilize the technical pearls presented herein to help reduce the amount of time spent in the operating room performing these clinically challenging revisions. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

An unusual case of a traumatic splenic rupture masquerading as myocardial ischemia: a case report

BackgroundThe spleen is one of the most frequently injured abdominal organs during trauma, which can result in intraperitoneal bleeding of life-threatening magnitude. Although splenic injury secondary to trivial trauma comprises a minor fraction of abdominal injuries, undiagnosed or delayed diagnosis may result in a complicated clinical course.Case presentationOne such event is presented here, wherein a late diagnosis of an advanced grade splenic injury following a trivial trauma initially presented in disguise as acute myocardial ischaemia in a previously healthy South Asian woman in her late 30s. Emergency laparotomy and splenectomy were performed with simultaneous massive transfusion for a 3.5-L blood loss. She subsequently had an uncomplicated clinical course with regular surgical follow-up.ConclusionSplenic injuries might present with ambiguous symptoms such as atypical chest pain and shoulder pain, necessitating attending clinicians to have a high degree of suspicion, especially in busy units such as the emergency department (ED).

Case Report: The Value of Vigilance and Iterative Evaluations with an Uncooperative Patient in the Emergency Department

A patient in the sixth decade of life presented to the Emergency Department (ED) with an apparent suicide attempt as well as with abdominal pain. The patient appeared to be inebriated. The prehospital emergency medicine service (EMS) providers suggested that the presentation may have been due to diabetic ketoacidosis. A chest x-ray finding showed possible pneumoperitoneum, but was read by radiology has having been seen on a chest x-ray from a year prior. Repeat physical examination continued to show abdominal tenderness, leading to a CT scan of the abdomen that demonstrated a large pneumo-peritoneum with a mild ileus and chronic surgical findings. The patient was transferred to a tertiary level of care for exploratory laparotomy after broad spectrum antibiotics and additional pain medication given. A bowel perforation was identified and was repaired. He had an uncomplicated clinical course and was discharged from the hospital 8 days later. The critical thinking skill of iterative reconsideration of a diagnosis along with iterative testing can avoid the pitfalls that can attend to such biases of cognition as anchoring and premature closure of thinking.

Co-infection of COVID-19 and Monkeypox: A Case Report from Florida, USA, 2022

Monkeypox is a re-emerging zoonotic disease of the orthopoxvirus genus presenting with myocutaneous symptoms similar to those caused by smallpox. Patients infected with monkeypox may experience a prodromal period with flulike symptoms lasting between 1-4 days, an asymptomatic incubation period lasting 7-17 days and a symptomatic rash period lasting 14-28 days between the appearance of widespread vesiculopapular lesions and desquamation. Specific risk factors for the current monkeypox outbreak include HIV infection, prior STI infection, male sex, young-adult age (specifically being in the 20’s-30’s age group), engaging in risky behaviors (such as unprotected sex) and men having sex with other men. We report the case of a 38-year old HIV+ patient testing positive for monkeypox, COVID-19 and herpes who presented to the emergency department with widespread vesiculopapular lesions. One week prior to ED presentation, the patient experienced flu-like symptoms including fever and, two days later, developed a vesiculopapular rash beginning on his face and spreading downwards to his extremities, trunk and genitalia. The flu-like symptoms developed twelve days after attending an event where the patient reported having sex with multiple other men. The patient was treated with intravenous fluids and supportive care alongside his HIV medications. Nine days after initial ED presentation, all skin lesions were desquamated and the patient was discharged from the hospital. To our knowledge, this is one of the first reported cases of co-infection with COVID-19 and monkeypox in Florida and the United States more broadly. Despite our patient’s several risk factors for monkeypox infection, and immunosuppressed status, he experienced an uncomplicated clinical course. As vaccination and antiviral treatments become more available for monkeypox patients, our case suggests supportive care with airborne and contact precautions may be adequate in the treatment of future monkeypox patients where these treatments are unavailable.

Mild Grisel Syndrome: Expanding the Differential for Posttonsillectomy Adenoidectomy Symptoms.

Tonsillectomy with or without adenoidectomy is the second most common pediatric surgical procedure in the United States with up to 97% performed as an outpatient.1,2 While it is largely a safe procedure, several complications have been described and are encountered in the emergency department and primary care setting. A 29-month child presented to the emergency department with neck stiffness 10 days after tonsillectomy and adenoidectomy. A computed tomography scan of the neck limited by motion artifact was unrevealing, but a consult to the pediatric otolaryngologist generated concern for Grisel syndrome, the atraumatic rotary subluxation of the atlantoaxial joint. While surgical intervention can be required, the patient had an uncomplicated clinical course and the anomalous neck posture resolved with time and antiinflammatories alone. Keeping a broad differential for posttonsillectomy and adenoidectomy patient concerns is important for the clinician. Serious, life-threatening complications can arise from Grisel syndrome while good functional outcomes can be achieved with timely and appropriate treatment.

Myocarditis following mRNA Covid-19 vaccination: A pooled analysis

BackgroundPost-marketing surveillance studies have raised concerns of increased myocarditis rates following coronavirus disease-19 (Covid-19) mRNA vaccines. The present study aims to accumulate the published mRNA Covid-19 vaccine-associated myocarditis cases, describe their clinical characteristics and determine the factors predisposing to critical illness. MethodsMedline, Scopus, Web of Science, CENTRAL and Google Scholar were systematically searched from inception. Studies reporting adult myocarditis cases following BNT162b2 or mRNA-1273 vaccination were included. Individual participant data coming from case reports/series were pooled. Proportional random-effects meta-analysis was conducted by combining the pooled cohort and observational studies with aggregated data. ResultsOverall, 39 studies were included with a total of 129 patients. Most cases occurred in young males after the second vaccine dose. Myocarditis after the first dose was significantly associated with prior Covid-19 (p-value: 0.025). The most common electrocardiographic finding was ST-segment elevation, while late gadolinium enhancement was invariably observed in cardiac magnetic reasoning. Logistic regression analysis demonstrated that signs of heart failure were predictive of subsequent critical illness (Odds ratio: 19.22, 95% confidence intervals-CI: 5.57–275.84). Proportion meta-analysis indicated that complete resolution of symptoms is achieved in 80.5% of patients (95% CI: 59.3–92.1), while the proportion of participants necessitating intensive care unit admission is 7.0% (95% CI: 3.8–12.9). ConclusionsMyocarditis following mRNA Covid-19 vaccination is typically mild, following an uncomplicated clinical course with rapid improvement of symptoms. Future research is needed to define its exact incidence, clarify its pathophysiology and determine the optimal management plan depending on its severity.Protocol registration: dx.https://doi.org/10.17504/protocols.io.bxwtppen.

Abstract 11313: Pericarditis Recurrence After Initial Uncomplicated Clinical Course

Introduction: Acute pericarditis is an inflammatory disease associated with a non-negligible risk of acute complications and future recurrence. The exact incidence of pericarditis recurrence in patients with a first uncomplicated clinical course is, however, unknown. Objectives: We sought to evaluate the incidence and clinical predictors of recurrence after a first episode of acute uncomplicated pericarditis in a large urban hospital in the USA. Methods: We conducted a retrospective review, through electronic health records, to complete a database that includes patients admitted with a first episode of acute pericarditis (according to ESC criteria) and then selected only those with uncomplicated course (without in-hospital death, large pericardial effusion [&gt;20 mm] or tamponade, constriction, or failure of treatment) at the VCU Medical Center (Richmond, VA) between 2009 and 2018. Results: A total of 240 patients met acute pericarditis criteria: 174 (72%) patients had an uncomplicated course (median age was 50 [interquartile range 34 to 62] years, 45% females, 51% Black). Pericarditis was considered idiopathic in 89 patients (51%). During a median follow-up time of 184 [17- 434] days, 23 (13%) patients experienced at least one episode of recurrent pericarditis. When compared with those without recurrence, patients with recurrent pericarditis were more frequently females (15 [65%] vs 63 [42%], p=0.035) and had a higher prevalence of subacute/delayed presentation (defined as symptoms over several days without a clear-cut acute onset) (3 [13%] vs 1 [0.7%], p=0.008). There were no other clinical (including the use of anti-inflammatory therapies and pericarditis etiology) or laboratory differences between those with and without pericarditis recurrence at follow-up. At multivariate logistic regression analysis only subacute presentation remained predictor of recurrence at follow-up (odds ratio 20, 95% confidence interval [1.81-198.11], p=0.014). Conclusions: Approximately one every six patients with an acute pericarditis experience a recurrence over a 6-month median follow-up despite an initial uncomplicated course. Subjects with subacute presentation were at significantly higher risk of recurrence.

Nationwide trends in middle meningeal artery embolization for treatment of chronic subdural hematoma: A population-based analysis of utilization and short-term outcomes

Middle meningeal artery (MMA) embolization represents a promising novel treatment modality for chronic subdural hematoma (cSDH), yet utilization and efficacy data are limited. This study evaluates the utilization and short-term outcomes of MMA embolization for cSDH treatment in a large national inpatient registry. cSDH patients treated with MMA embolization and/or surgical evacuation (craniotomy/burr hole drainage) were identified using the National Inpatient Sample (NIS) during 2012–2018 period. Temporal trends, complications, and discharge disposition were evaluated, and propensity score matching was implemented for adjusted comparisons and to mitigate confounding by indication. Among 60,045 cSDH patients identified, 390 (0.6%) underwent MMA embolization. Embolized patients presented more with high acute illness severity subclasses in comparison with surgically evacuated patients (53% vs. 34%, p = 0.004) yet did not experience any procedure-related hemorrhagic or ischemic complications. Although discharge disposition did not differ from those surgically managed, embolized patients had longer mean hospital stays (13 vs. 8 days, p = 0.023) and accrued greater hospital charges (p < 0.001). Following propensity adjustment, length of stay and charges remained greater in the embolization cohort, yet rates of routine discharge increased appreciably (40% vs. 30%, p = 0.141) relative to surgically treated cSDH patients. The utilization of embolization increased exponentially after 2015, reaching an apex in 2018 (3.7% of treated cSDH). This population-based national assessment demonstrates exponential increases in utilization of MMA embolization for cSDH treatment in recent years. Embolized patients had uncomplicated clinical courses and similar discharge dispositions as surgical evacuation patients. Large-scale prospective trials are warranted to further assess the efficacy of this modality.

Pericarditis Recurrence After Initial Uncomplicated Clinical Course

Acute pericarditis is an inflammatory disease associated with a non-negligible risk of acute complications and future recurrence. However, the exact incidence of pericarditis recurrence in patients with a first uncomplicated clinical course is unknown. We sought to evaluate the incidence and clinical predictors of recurrence after a first episode of acute uncomplicated pericarditis in a large urban hospital in the United States. We conducted a retrospective review, through electronic health records, to complete a database that includes patients admitted with a first episode of acute pericarditis and selected only those with an uncomplicated course (without in-hospital death, large pericardial effusion [>20 mm] or tamponade, constriction, or incessant pericarditis) at the VCU Medical Center (Richmond, Virginia) from 2009 to 2018. A total of 240 patients met acute pericarditis criteria: of the 240 patients, 164 patients (68%) had an uncomplicated course (median age [interquartile range] in years: 50 [32 to 62], 43% females). The median follow-up time was 186 (19 to 467) days. Pericarditis was idiopathic in 84 patients (51%). Fifteen patients (9%) had at least 1 episode of recurrent pericarditis. Compared with those without recurrence, patients with recurrent pericarditis were younger (37 [25 to 59] vs 51 [34 to 62] years, p=0.034), had a higher prevalence of subacute/delayed presentation (2 [13%] vs 1 [1%], p=0.023), and less frequently received colchicine (6 [40%] vs 100 [67%], p=0.036). At multivariate logistic regression analysis, subacute presentation and younger age remained predictors of recurrence at follow-up. In conclusion, 9% of patients with acute pericarditis experienced a recurrence over a 6-month median follow-up despite an initial uncomplicated course. Younger age and subacute presentation were associated with a significantly increased risk of recurrence.

ФАКТОРЫ, ВЛИЯЮЩИЕ НА КЛИНИЧЕСКОЕ ТЕЧЕНИЕ ПЕРЕЛОМОВ НИЖНЕЙ ЧЕЛЮСТИ И ДЛИТЕЛЬНОСТЬ ВРЕМЕННОЙ НЕТРУДОСПОСОБ-НОСТИ

Thing. Among the fractures of the bones of the facial skeleton are most often re-breaking down the lower jaws. The diagnosis of them does not represent difficulties, but despite this, the clinical course of the lower jaw fractures is often complicated by the development of herbal osteomyelitis, which affects the reparative processes in the bone and for the duration of the temporary disability of patients. In connection with the foregoing, the study of factors af-fecting the clinical course of the lower jaw fractures, and the investigator, but on the duration of the temporary disability of patients, is relevant. Purpose — to study the factors influencing the clinical course of mandibular fractures and the timing of temporary disability of patients Methodology. An analysis of 918 stories of the disease of patients with fractures of the Low-er Chelf. The share of traumatic osteomyelitis is determined. Possible factors that contribute to the development of this complication and an increase in the duration of temporary disability is studied. Results. The development of traumatic osteomyelitis in the fractures of the lower jaw is due to the complex of interrelated factors. The most significant among them are: non-timely appeal of the victims of specialized help, senior wagon, poor-quality assistance in the pre-hospital stage, the presence of a stroke of Zu-Ba, having a chronic infection in the periapical tissues and the incorrect tactics of the doctor in relation to this tooth, Multiple fractures on one side of the chemistry, the choice of the method of fixing fragments. The duration of the temporary disability of patients with the development of traumatic osteomyelitis is significantly larger than with the uncomplicated clinical course of the lower jaw fractures. Conclusions. In order to reduce the frequency of development of traumatic osteomyelitis, it is necessary to conduct targeted prophylactic work aimed at improving the quality of the provi-sion of specialized assistance to patients with fractures of the lower person, both in the dogoital and hospital stages.

Low Risk of Hypertrophic Cardiomyopathy With Contemporary Management Strategies Implemented in Non-Referral Regional Community-Based Practices

Major advances in diagnosis and treatment have emerged for hypertrophic cardiomyopathy (HCM), largely in major tertiary referral centers dedicated to this disease. Whether these therapeutic benefits are confined to patients in such highly selected cohorts, or can be implemented effectively in independent regional or community-based populations is not generally appreciated. We assessed management and clinical outcomes in a non-referral HCM center (n = 214 patients) in Eastern Pennsylvania. Over a 6.0 ± 3.2-year follow-up, the HCM-related mortality rate was 0.1% per year attributed to a single disease-related death, in a 49-year-old man with end-stage heart failure, ineligible for heart transplant. Fifteen patients (7%) with prophylactically placed implantable cardioverter-defibrillators (ICDs) experienced appropriate therapy terminating life-threatening ventricular tachyarrhythmias. In 23 other patients (11%; 5%/year), heart failure due to left ventricular outflow obstruction was reversed by surgical septal myectomy (n = 20) or percutaneous alcohol septal ablation (n = 3). This regional HCM cohort was similar to a comparison tertiary center referral population in terms of HCM-mortality: 0.1%/year vs 0.3%/year (p = 0.3) and ICD therapy (31% vs 16% of primary prevention implants), although more frequently with uncomplicated benign clinical course (62% vs 46%; p <0.01). In conclusion, effective contemporary HCM management strategies and outcomes in referral-based HCM centers can be successfully replicated in regional and/or non-referral settings. Therefore, HCM is now a highly treatable disease compatible with normal longevity when assessed in a variety of clinical venues not limited to tertiary centers.

Leiomyosarcoma of Urinary Bladder, A Review of Two Cases

Abstract Introduction/Objective Leiomyosarcomas of the urinary bladder are rare smooth muscle tumor, and constitute 1% of all bladder malignancies. Although rare, leiomyosarcoma is a clinically significant disease, presenting as a high-grade advanced malignancy with associated substantial morbidity and mortality, if not treated early. The diagnosis can be delayed because of the asymptomatic presentation until the tumor reaches an advanced stage. Methods We present two cases of leiomyosarcoma of the urinary bladder. First case: a 63 years old female with a history of cervical carcinoma treated with radiation, 25 years ago, followed by uncomplicated clinical course, until recent development of vesicovaginal fistula. During her work up with cystoscopy, a large bladder mass was identified. Second case: a 71 years old female with a history of treated breast cancer, who presented with recurrent history of cystitis and hematuria. Cystoscopy revealed a nodular mass in the right posterior bladder wall. Results Microscopically, both lesions were highly cellular with infiltrative, interlacing fascicles of spindle cells and associated mitosis, cellular atypia and necrosis. Immunohistochemistry revealed positive expression of muscle- specific actin, desmin, and caldesmon; with negative expression of ALK-1, EMA, Cytokeratins and GATA3, in both the cases. Other spindle cell lesions including, leiomyoma, inflammatory myofibroblastic tumor and sarcomatoid carcinoma were included in the differential diagnosis, and ruled out by morphology and immunohistochemistry. Conclusion Our cases highlight the importance of awareness of the occurrence of leiomyosarcomas, a rare manifestation in bladder. Although rare, but they present with a poor outcome. The differential diagnosis of spindle cell lesions is extensive, including close benign and malignant mimics, the treatment of all being very different. Immediate radical cystectomy has been associated with longer survival rates for leiomyosarcoma. Leiomyosarcoma, being aggressive, with associated high recurrence rate and metastatic potential, an early correct diagnosis would aid in the institution of proper management.