St. Joseph's Hospital

Background Flow-diverting stents (FDS) have revolutionized the treatment of large, giant, and wide-neck intracranial aneurysms. FDS promote thrombosis and aneurysm occlusion by redirecting blood flow within the parent artery. This method of endovascular therapy has proven efficacious, although leaving room for improvement. This study evaluated computational flow dynamics (CFD) and technical feasibility of the novel Surpass Elite FDS (Elite) in comparison with the Pipeline Embolization Device with Shield Technology (PED-Shield) across seven in vitro aneurysm models. Methods Surpass Elite FDS and PED-Shield were assessed primarily with three CFD metrics to quantify flow diversion: inflow rate reduction, impact zone reduction, and turnover time. Seven patient-specific aneurysm models were utilized. These included one basilar tip, one vertebral artery, two middle cerebral artery, and three internal carotid artery aneurysms. Further evaluation of pore densities and velocity profiles was performed to create a robust comparison summary. Results Surpass Elite FDS demonstrated greater reduction in inflow rate and impact zone with improved turnover time in all models. Elite additionally displayed higher pore densities at nearly all proximal (inlet), aneurysm, and distal (outlet) points across the aneurysm models. Conclusions The next-generation Surpass Elite established better CFD metrics in comparison with PED-Shield in all in vitro aneurysm models evaluated here. Further, Elite demonstrated a higher pore density at nearly all aneurysm points assessed in this study, promoting enhanced flow diversion and thrombosis in the aneurysm sac. Considering these findings, Elite has strong potential to improve on the occlusion rates of PED-Shield.

Background Postoperative pain remains a common concern following ventral hernia repair (VHR), especially for open procedures. We aim to assess the effectiveness of the Transversus Abdominis Plane (TAP) block for the management of postoperative pain following VHR. Methods Cochrane, EMBASE, and PubMED, MEDLINE, and Web of Science were systematically searched for studies comprising adults undergoing VHR with preoperative TAP block, compared to placebo and epidural analgesia. The outcomes selected for analysis were postoperative pain with the numeric rating scale (NRS), postoperative morphine milligram equivalents (MME) per day, and hospital length of stay (LOS). Subgroup analysis was performed for studies using the Liposomal Bupivacaine (Exparel®) for TAP block. Results 1,460 results were screened, and 14 included, comprising 9 retrospective cohort studies and 5 RCTs, totaling 1,617 patients. TAP block was associated with a shorter LOS compared to conventional pain measures (MD -1,14 days; 95% CI -2.05, -0.22; P = 0.014) and to epidural analgesia (MD -2.02 days; 95% CI -2.67, -1.37; P < 0.001), and lower NRS scale in the day of surgery (MD -1.24; 95% CI -1.81, -0.68; P < 0.001) and in the POD1 (MD -0.63; 95% CI -1.18, -0.08; P = 0.025) compared to placebo. No benefit was seen for TAP block regarding opioid consumption compared to epidural analgesia and placebo. No differences were seen between TAP block and epidural analgesia for the NRS scores. Subgroup analysis of Exparel® compared to simple bupivacaine showed no benefit for Exparel®. Conclusions The TAP block is associated with shorter LOS compared to placebo and epidural analgesia and is related to less early postoperative pain compared to the conventional pain measures. The TAP block should be considered as a pain management modality for VHR, however cost-effective analysis is required to address the feasibility of the routine utilization of this approach and to balance the financial benefits of its application.

Isolated hand weakness due to stroke is rare and is often misdiagnosed as a peripheral lesion. Isolated central hand and finger weakness can present as pseudomedian, pseudoulnar, and/or pseudoradial nerve palsy. Here, we describe a patient who presented with a median claw hand due to cortical infarct.

BACKGROUND AND OBJECTIVES After surgical drainage of a chronic subdural hematoma (cSDH), middle meningeal artery (MMA) embolization aids in preventing the revascularization of the cSDH membranes at the capillary level and, in turn, reaccumulation. With the MMA circulation ipsilateral to the surgical side often being disrupted, there is recruitment of collaterals from the contralateral MMA tree to the ipsilateral cSDH membranes. The aim of this study was to demonstrate the ability of additive contralateral liquid embolic (LE) injection after ipsilateral surgery to augment MMA embolization. We hypothesized that contralateral LE injection may provide additional MMA embolization to the affected ipsilateral side and increase response to treatment. METHODS Consecutive cases of unilateral cSDH surgery with ipsilateral MMA embolization and additive contralateral LE injection were retrospectively identified from a prospectively maintained database of the senior authors. RESULTS Over the study period, 26 consecutive cases of recurrent cSDH after unilateral surgery were identified. There was an average age of 73 ± 2.7 years (range 27-90 years), and 14 patients (54%) were female. All 26 patients (100%) had previous burr holes or a craniotomy. The average cSDH thickness after surgery and before embolization was 10 ± 0.3 mm, and the average midline shift was 3.5 ± 0.7 mm. Of the 26 patients who underwent bilateral MMA embolization, 96% had over-the-top contralateral-to-ipsilateral LE injection and penetration, providing additional embolization to membranes of the index ipsilateral cSDH. The average cSDH thickness on follow-up was 4 ± 5 mm and midline shift of 0.2 ± 0.7 mm. Complete cSDH resolution was achieved in 7 patients (39%). Two patients had cSDH recurrence, one of which required reoperation. There were no LE or catheter-related complications. CONCLUSION Contralateral MMA embolization in patients who have undergone ipsilateral cSDH evacuation and traditional ipsilateral MMA embolization allows for over-the-top LE penetration of cSDH membranes, thereby further augmenting the desired ipsilateral MMA embolization.

Introduction Flow diverting stents (FDS) are routinely used to reconstruct the arteries of the head and neck. When placed into the mobile cervical internal carotid artery (cICA) segment, the FDS runs the risk of post-procedure stent migration and proximal intimal hyperplasia reaction from physiologic movement of the neck. We report our experience using a novel proximal anchoring technique during endovascular flow reconstruction of complex petrocervical dissections to prevent this potentially deleterious result. Methods We reviewed a prospectively maintained IRB-approved institutional database of the senior authors to identify cases of FDS treatment in the mobile petrocervical segments which had the proximal FDS “anchored” with a nitinol stent. Results The proximal anchoring technique was successfully performed in the mobile cervical segment in a total of 31 cases over the study period. Each case involved a complex ICA dissection with 68% (n = 21) having an accompanying pseudoaneurysm. Fifty-two percent (n = 16) were female. Surpass Streamline and Evolve FDS were utilized in all cases. An average of 2.2 ± 0.1 FDS devices were utilized (range 2-4 FDS), with each case utilizing a laser-cut nitinol carotid stent as the proximal anchor. The average stent diameter was 5.64 ± 0.2 mm (range 4-8 mm) and length of 30.1 ± 1.5 mm (range 20-60 mm). On last follow-up angiography, there were no instances of stent migration or proximal neointimal hyperplasia. Conclusion Utilization of the proximal anchoring technique on FDS constructs in the mobile cICA may provide additional protection from post-procedure stent migration and intimal reaction attributed to patient neck movement resulting in augmentation of successful healing.

Purpose Risks of occupational exposures to hazardous drugs (HDs) have been documented and identified as needing to be monitored. To decrease potential exposures in a community hospital, this project evaluated the impact of implementing a hazardous drug wipe sampling technology (BD HD Check system; BD, Franklin Lakes, NJ) and accompanying environmental procedures, risk level scoring assessment, and recordkeeping tools on identifying HD surface contamination. Methods The 16-week evaluation focused on HD wipe sampling of locations (25 sites) within a cleanroom suite and infusion areas at the largest hospital of a multihospital community health system. Sites were determined through a risk stratification assessment to which areas were given a high, medium, or low-risk category to determine frequency of testing. HD wipe samples were tested for methotrexate, doxorubicin, and cyclophosphamide. Standard operating procedures (SOPs) were developed to address testing, decontamination, and retesting procedures. Results A total of 238 samples were collected over 16 weeks across 25 sample sites. Fifteen of 25 sites resulted in at least 1 positive, totaling 37 initially positive results. Following initial positives, 92.5% of sites successfully tested negative following decontamination. Three sites that remained positive after decontamination underwent a corrective and preventative action (CAPA) analysis and were negative after a second round of decontamination. Conclusion Sampling led to reduction in contamination and more transparency in HD monitoring. The HD wipe sampling technology (BD HD Check system) and accompanying procedures were shown to be helpful in establishing and refining SOPs for HD preparation, cleaning/decontamination, and wipe sampling.

Cardiovascular Magnetic Resonance 2024 Conference (CMR2024) convened in London, UK, from 24 to 26 January 2024 and brought together 2705 learners and renowned cardiac imaging professionals to discuss and learn about the latest advancements. Organized by the Society for Cardiovascular Magnetic Resonance (SCMR) and the European Association of Cardiovascular Imaging (EACVI), in collaboration with the European Society of Cardiovascular Radiology (ESCR), CMR2024 was the largest international cardiac magnetic resonance conference to date. This conference underscored the collaboration between cardiologists, radiologists, scientists, and technologists by bringing together three major societies—SCMR, EACVI, and ESCR. Innovative session formats like ‘Shark Tank’ and ‘Workflow, Innovations & Patients’ facilitated expert opinion and practical experiences sharing in a ‘TED-talk style’. With over 1168 abstract submissions and 75% acceptance rate, the programme featured multiple Early Career Award sessions, oral scientific sessions, oral case sessions, and rapid-fire sessions, all categorized by topic. Highlights included patient- and physician-centred imaging sessions, sharing referring physicians’ and patients’ insights of incremental value of cardiovascular magnetic resonance (CMR) in patient’s management. The programme offered invited lectures in eight parallel tracks with three plenary and two keynote speakers. In addition, the interactive workshops and panel discussions provided a platform for knowledge exchange, support, and collaboration. A great emphasis was placed on collaboration between radiologists, cardiologists, scientists, and technologists, showcasing an ideal cardiac imaging marriage as a model for enhanced patient care around the globe. The event also featured exhibitions of the latest CMR technology and software, offering attendees a glimpse into the future cardiac imaging. CMR2024 emerged as a remarkable scientific, educational, and networking event, inspiring attendees to learn and collaborate within the global CMR community.

Background Soluble forms of progenitor cell receptors may be implicated in the delayed erythropoietic response during severe anemia. In this study, plasma levels of soluble erythropoietin receptor (sEPO‐R) and soluble granulocyte, macrophage‐colony stimulating factor receptor (sGM‐CSFR) were assessed in Plasmodium falciparum‐infected children in Ghana. Methods This case‐control study was conducted at Tamale Teaching Hospital, Ghana. One hundred and twenty P. falciparum‐infected, and 60 uninfected children aged 12–144 months were recruited from April to July, 2023. About 4 mL of blood was collected for malaria microscopy, full blood count using a haematology analyser, and sEPO‐R, sGM‐CSFR and erythropoietin (EPO) estimation using enzyme‐linked immunosorbent assays. Data were analyzed using SPSS version 26.0. Results Plasma levels of sEPO‐R were higher among participants with severe malarial anemia (SMA) than those in the non‐SMA and control groups (p < 0.001). Plasma sGM‐CSFR levels were higher in P. falciparum‐infected children than in controls, but the levels were similar between the SMA and non‐SMA groups. Hemoglobin (r = −0.823, p < 0.001), RBC (r = −0.852, p < 0.001), HCT (r = −0.790, p < 0.001) and platelets (r = −0.810, p < 0.001) negatively correlated with sEPO‐R. There was a strong positive correlation between sEPO‐R and EPO in P. falciparum‐infected children (r = 0.901, p < 0.001). Plasma sEPO‐R better predicted severe anemia among malaria‐infected children (cut‐off point: 161.5 pg/mL, sensitivity: 96.0%, specificity: 82.9%, AUC: 0.964, p < 0.001). Conclusion P. falciparum‐infected children had higher plasma levels of sGM‐CSFR, sEPO‐R and EPO. Plasma sEPO‐R correlated negatively with erythrocyte parameters, suggesting a possible contribution of the endogenous receptor to the development of severe anemia in children with malaria. Further studies to investigate the neutralizing effects of sEPO‐R on erythropoietic response during malaria are recommended.

Background: Randomized clinical trials have demonstrated that IV thrombolysis (IVT) can be administered safely in wake-up stroke (WUS) after MRI- or CT-based imaging selection to improve clinical outcomes. The objective of this study was to evaluate the utilization of IVT to treat WUS using a standardized WUS protocol across a healthcare system. Methods: A WUS protocol using MRI-based imaging selection was implemented across an academic healthcare system with 6 acute care hospitals in the state of Georgia. We prospectively identified all WUS patients who underwent the WUS protocol over a 12 month period through August 15, 2024. Patients were eligible for the WUS protocol if they presented with disabling symptoms identified on awakening, had a CT head without contrast showing no hypodensity to explain clinical symptoms and had CT angiography of the head and neck demonstrating no large vessel occlusion as a cause of symptoms. All patients underwent expedited brain MRI sequences (DWI, T2w FLAIR, GRE) without contrast and IVT was administered at the discretion of the treating neurologist. Results: During the study period, the WUS protocol was activated for 27 patients of which 6 (22%) received IVT (median NIHSS 10, IQR 5-15). Reasons for not receiving IVT included lack of DWI-FLAIR mismatch on MRI (n=11), DWI negative MRI (n=8), IVT declined by patient (n=1) and IVT contraindication (n=1). A modified Rankin scale of 0-1 at 90 days was achieved in 67% of WUS patients treated with IVT and no symptomatic intracerebral hemorrhages. Door-to-needle time within 60 minutes was significantly less likely in WUS compared with non-WUS cases (0% vs 69%, p=0.001). IVT administration in WUS patients made up 2% of all acute ischemic stroke patients receiving IVT. Conclusions: An MRI-based WUS protocol was able to identify a small subset of acute ischemic stroke patients who met eligibility criteria for IVT outside of the 4.5 hour time window. IVT was associated with good clinical outcomes and not associated with any complications.

Objective Caesarean section (CS) rates in Sri Lanka have escalated significantly, with projections indicating that over half of all births may involve CS by 2025. To address this rise and mitigate maternal morbidity, it is essential that CS procedures are medically justified. This study evaluates RobsApp®, a novel smartphone application designed to collect high-quality prospective data on CS rates based on the Robson classification. Methods The study utilized RobsApp® for data collection in the Professorial Unit of De Soysa Hospital for Women (DSHW), Sri Lanka. Data were collected prospectively from 1,712 deliveries between April and October 2019. The analysis focused on CS rates across different Robson categories and the quality of the collected data, comparing them with previous data obtained using traditional methods. Results The overall CS rate was 33.0%, with Robson category 5a accounting for most cases. Emergency CS constituted 49.6% of all procedures, with cardiotocograph (CTG) abnormalities being the leading indication. The quality of the data collected through RobsApp® met the standards recommended by the Robson guidance, as evidenced by the study's ability to accurately categorize deliveries and assess CS rates. Conclusions RobsApp® has proven to be an effective tool for prospective data collection, aligning well with Robson guidelines and facilitating high-quality data gathering. The study reveals a rising trend in CS rates at DSHW, particularly for reasons beyond previous CS. The inclusion of demographic data and birth weight analysis in future studies will enhance comparisons and insights into reducing CS rates. Ethics Ethical approval was obtained from the Ethical Review Committee, Faculty of Medicine, University of Colombo (Ref – EC-19–024) which waived the need for individual consent. Study adhered to the Helsinki Declaration.

Vaccine hesitancy is a significant global issue and is recognized by the World Health Organization (WHO) as one of the most pressing threats to public health. Defined as the delay in acceptance or refusal of vaccines despite their availability, vaccine hesitancy undermines decades of progress in preventing vaccine-preventable diseases. The issue is complex, influenced by misinformation, distrust in healthcare systems, cultural beliefs, and access barriers. These challenges require innovative and empathetic solutions to increase vaccine acceptance. Addressing this growing epidemic requires a multifaceted approach, which involves broader strategies and policymaking and in addition, effective communication tools for clinicians. Motivational Interviewing (MI), a patient-centered communication technique, offers an effective strategy to address pediatric vaccine hesitancy by fostering trust, understanding, and informed decision-making. This review aims to explore the problem of pediatric vaccine hesitancy in the United States, examine its underlying factors, and highlight evidence-based strategies, including Motivational Interviewing, to address this growing concern in clinical and public health settings. It offers practical guidance for healthcare providers and pediatricians to tackle this growing problem effectively and emphasizes the need for a combined effort of communication, community outreach, education, and systemic policy to overcome vaccine hesitancy.

Background In low and middle-income countries like Ghana, out-of-pocket (OOP) payments remain a significant barrier to healthcare access, often leading to catastrophic health expenditures (CHE). This study evaluates the incidence of CHE among patients treated for long bone fractures at Ghana’s major teaching hospitals, providing insight into the economic burdens faced by these patients. Methods This cross-sectional study analyzed data from 2,980 patients with long bone fractures treated at four major teaching hospitals in Ghana from July 2017 to July 2020. We collected demographic, clinical, and economic data, including OOP payments and patient-reported income, to assess the incidence of CHE at varying income thresholds (10%, 20%, 30%, 40%). Logistic regression models were used to identify predictors of CHE, with variables including age, gender, education, region, fracture type, injury severity, and NHIS coverage. Results The incidence of CHE was highest at the 10% income threshold (53.21%) and decreased with higher thresholds. Male patients incurred higher average OOP payments ($343.68) than females ($271.63), and patients with tibia fractures faced the highest financial burden. Educational and regional disparities were evident, with lower CHE rates among patients with higher educational attainment and those from northern regions. NHIS coverage provided limited financial relief, particularly at lower income thresholds. Conclusion Long bone fractures impose a substantial financial burden on patients in Ghana, with significant gender, educational, and regional disparities in OOP payments and CHE. While NHIS provides some relief, it remains inadequate in protecting patients from financial distress. Policy interventions aimed at expanding NHIS coverage, reducing OOP payments for high-cost treatments, and addressing geographic inequities are urgently needed to improve financial protection for patients with long bone fractures in Ghana. Future research should focus on capturing long-term financial impacts and improving income data accuracy to better inform healthcare policies.

This study investigates the potential clinical synergy between the PARP inhibitor niraparib (Zejula) and concomitant statins, exploring their combined effects on progression-free survival (PFS) in patients with ovarian cancer. We retrospectively analyzed niraparib registrational clinical trials in ovarian cancer to investigate potential interactions between niraparib and statins. In the PRIMA trial, patients receiving niraparib demonstrated improved PFS compared with those on placebo (HR = 0.62; P < 0.001; median PFS 13.8 vs. 8.2 months). The post hoc analysis revealed that patients receiving maintenance niraparib who reported concomitant use of statins exhibited significantly improved PFS compared with those on placebo with concomitant statins (HR = 0.34; P < 0.001; median PFS 18.2 vs. 6.0 months). Notably, the improved efficacy in the two-arm comparison of concomitant statin patients was much better than that in the two-arm comparison of those patients without statin, as reflected in the niraparib–statin interaction (P = 0.005). These findings suggest novel opportunities in oncology for the use of statins in combination therapies with PARP inhibitors and emphasize the need for further investigation. Significance The presented retrospective analysis suggests, to the best of our knowledge for the first time, a potential significant interaction between statins and niraparib in clinical settings. Nevertheless, further investigations are required to gain a better understanding of the potential clinical benefit.

Bilateral medial medullary infarct with Heart like appearance in MRI brain

Background Electrodiagnostic (EDX) studies are critical for surgical decision-making in nerve injuries. Surgeons typically rely on the electrodiagnostician’s reports and lack formal training in EDX interpretation. This knowledge gap highlights a need for accessible and effective educational resources for surgeons to improve their understanding of EDX and enhance patient care. Methods The educational module consisted of a pre-lecture knowledge assessment, a 42-minute video lecture on interpreting electrodiagnostic studies, and a post-lecture knowledge assessment. Knowledge retention was assessed via an additional survey distributed three months after module completion. Results This study, involving 119 participants (79% attending surgeons, 8% fellows, 9% surgical residents, and 2% who described their position as “other”), demonstrated that a 42-minute video-based learning module significantly improved knowledge of EDX interpretation. Median scores increased from 7 to 9 (p<0.001), with improvement persisting at three months (median retention score of 11, p<0.025). Notably, among surgeons completing the three-month assessment, 65.5% reported that knowledge gained from the module had changed their clinical practice. Conclusion This study demonstrates that a concise, video-based learning module can effectively enhance surgeon knowledge of EDX interpretation and may serve as a valuable tool for surgical education and improving patient selection in nerve surgery.

Infective endocarditis (IE) is a life-threatening condition with increasing global incidence, primarily caused by Staphylococcus aureus, especially methicillin-resistant strains (MRSA). Biofilm formation by S. aureus is a critical factor in pathogenesis, contributing to antimicrobial resistance and complicating the treatment of infections involving prosthetic valves and cardiovascular devices. Biofilms provide a protective matrix for MRSA, shielding it from antibiotics and host immune defenses, leading to persistent infections and increased complications, particularly in cases involving prosthetic materials. Clinical manifestations range from acute to chronic presentations, with complications such as heart failure, embolic events, and neurological deficits. Diagnosis relies on the Modified Duke Criteria, which have been updated to incorporate modern cardiovascular interventions and advanced imaging techniques, such as PET/CT (positron emission tomography, computed tomography), to improve the detection of biofilm-associated infections. Management of MRSA-associated IE requires prolonged antimicrobial therapy, often with vancomycin or daptomycin, needing a combination of antimicrobials in the setting of prosthetic materials and frequently necessitates surgical intervention to remove infected prosthetic material or repair damaged heart valves. Anticoagulation remains controversial, with novel therapies like dabigatran showing potential benefits in reducing thrombus formation. Despite progress in treatment, biofilm-associated resistance poses ongoing challenges. Emerging therapeutic strategies, including combination antimicrobial regimens, bacteriophage therapy, antimicrobial peptides (AMPs), quorum sensing inhibitors (QSIs), hyperbaric oxygen therapy, and nanoparticle-based drug delivery systems, offer promising approaches to overcoming biofilm-related resistance and improving patient outcomes. This review provides an overview of the pathogenesis, current management guidelines, and future directions for treating biofilm-related MRSA IE.