Acute systemic hypotension after arteriovenous fistula construction in a patient with severe aortic stenosis

We report the case of a 53-year-old hemodialysis patient with severe aortic stenosis, who developed acute systemic hypoperfusion after arteriovenous fistula (AVF) construction. He presented with hypotension and repeated syncope soon after distal radiocephalic AVF construction, and finally developed a respiratory arrest. His blood pressure and hemodynamics recovered promptly by sub-emergent aortic valve replacement surgery. In the present case, the heart with severe aortic stenosis could not increase cardiac output in response to the reduction in peripheral vascular resistance caused by the AVF. High-output heart failure, a relatively rare AVF-associated disorder, occurs with an excessive AVF flow, usually more than 3 L/min or 30% of cardiac output. However, heart failure may develop soon after construction of an AVF with a moderate blood flow if a patient’s cardiac function is severely impaired. In addition, heart failure may improve with AVF preservation if the underlying heart disease is treatable.     

Presence of Modic type 1 change increases risk of postoperative pyogenic discitis following decompression surgery for lumbar canal stenosis

Study Design

Multicenter retrospective study.

Malignant pulmonary epithelioid hemangioendothelioma with hilar lymph node metastasis

Few cases each of malignant pulmonary epithelioid hemangioendothelioma (PEH) and PEH with lymph node metastasis have been reported. Here we report a case of PEH with lymph node metastasis. A Japanese woman was found to have a 2-cm-diameter mass with small satellite nodules in the right upper lobe of the lung. Microscopic examination revealed solid destructive growth of the main tumor, with epithelioid cells showing cytologic atypia and 3 mitotic figures per 10 high-power fields. Some of the tumor cells had intracytoplasmic lumina that appeared as vacuoles. These lumina were negative for alcian blue and periodic acid Schiff, and contained erythrocytes. However, erythrocytes were seen more frequently within small but distinct vascular channels that were arranged diffusely in the periphery of the main tumor. Other satellite nodules showed conventional PEH morphology. In hilar lymph nodes, the tumor cells resembled those of the main tumor. The vascular origin of the main tumor and satellite nodules was demonstrated by positive immunoreactivity for some endothelial markers. Although the diagnostic features of malignant PEH are not clear, those for PEH in other organs have included nuclear atypia, many mitoses, presence of necrosis, large tumor size, and spindle cell proliferation. The present case met these criteria, except for large tumor size and spindle cell proliferation. In conclusion, atypical cytologic features, the presence of necrosis, a high Ki-67 labeling index, and accompanying nodules of conventional PEH in the same pulmonary lobe suggest that this case was a malignant PEH with hilar lymph node metastasis.     

A case of malignant pleural mesothelioma with osseous and cartilaginous differentiation

A 69-year-old man with a history of exposure to asbestos was admitted because of a chest radiographic abnormality. Subsequent findings from computed tomography and a thoracoscopic biopsy suggested malignant mesothelioma. Punctate calcification was observed in the pleural tumor on computed tomography scanning. The patient underwent pleuropneumonectomy, and the tumor was pathologically diagnosed as malignant mesothelioma, sarcomatoid type with osseous and cartilaginous differentiation. Malignant mesothelioma with osseous and cartilaginous differentiation is a rare condition. Punctate calcification in the pleural mass as a lesion distinct from the pleural plaque may indicate osseous or osteosarcomatous differentiation in malignant mesothelioma.     

Vertebral derotation in adolescent idiopathic scoliosis causes hypokyphosis of the thoracic spine

The underlying purpose of this commentary and position paper is to achieve evidence-based recommendations on prevention of work-related musculoskeletal disorders (MSDs). Such prevention can take different forms (primary, secondary and tertiary), occur at different levels (i.e. in a clinical setting, at the workplace, at national level) and involve several types of activities. Members of the Scientific Committee (SC) on MSDs of the International Commission on Occupational Health (ICOH) and other interested scientists and members of the public recently discussed the scientific and clinical future of prevention of (work-related) MSDs during five round-table sessions at two ICOH conferences (in Cape Town, South Africa, in 2009, and in Angers, France, in 2010). Approximately 50 researchers participated in each of the sessions. More specifically, the sessions aimed to discuss new developments since 1996 in measures and classification systems used both in research and in practice, and agree on future needs in the field. The discussion focused on three questions: At what degree of severity does musculoskeletal ill health, and do health problems related to MSDs, in an individual worker or in a group of workers justify preventive action in occupational health? What reliable and valid instruments do we have in research to distinguish ??normal musculoskeletal symptoms?? from ??serious musculoskeletal symptoms?? in workers? What measures or classification system of musculoskeletal health will we need in the near future to address musculoskeletal health and related work ability? Four new, agreed-upon statements were extrapolated from the discussions: 1. Musculoskeletal discomfort that is at risk of worsening with work activities, and that affects work ability or quality of life, needs to be identified. 2. We need to know our options of actions before identifying workers at risk (providing evidence-based medicine and applying the principle of best practice). 3. Classification systems and measures must include aspects such as the severity, frequency, and intensity of pain, as well as measures of impairment of functioning, which can help in prevention, treatment and prognosis. 4. We need to be aware of economic and/or socio-cultural consequences of classification systems and measures.     

Polygenic Risk Score of Adolescent Idiopathic Scoliosis for Potential Clinical Use

Adolescent idiopathic scoliosis (AIS) is a common disease causing three-dimensional spinal deformity in as many as 3% of adolescents. Development of a method that can accurately predict the onset and progression of AIS is an immediate need for clinical practice. Because the heritability of AIS is estimated as high as 87.5% in twin studies, prediction of its onset and progression based on genetic data is a promising option. We show the usefulness of polygenic risk score (PRS) for the prediction of onset and progression of AIS. We used AIS genomewide association study (GWAS) data comprising 79,211 subjects in three cohorts and constructed a PRS based on association statistics in a discovery set including 31,999 female subjects. After calibration using a validation data set, we applied the PRS to a test data set. By integrating functional annotations showing heritability enrichment in the selection of variants, the PRS demonstrated an association with AIS susceptibility (p = 3.5 × 10⁻⁴⁰ with area under the receiver-operating characteristic [AUROC] = 0.674, sensitivity = 0.644, and specificity = 0.622). The decile with the highest PRS showed an odds ratio of as high as 3.36 (p = 1.4 × 10⁻¹⁰) to develop AIS compared with the fifth in decile. The addition of a predictive model with only a single clinical parameter (body mass index) improved predictive ability for development of AIS (AUROC = 0.722, net reclassification improvement [NRI] 0.505 ± 0.054, p = 1.6 × 10⁻⁸), potentiating clinical use of the prediction model. Furthermore, we found the Cobb angle (CA), the severity measurement of AIS, to be a polygenic trait that showed a significant genetic correlation with AIS susceptibility (rg = 0.6, p = 3.0 × 10⁻⁴). The AIS PRS demonstrated a significant association with CA. These results indicate a shared polygenic architecture between onset and progression of AIS and the potential usefulness of PRS in clinical settings as a predictor to promote early intervention of AIS and avoid invasive surgery. © 2021 American Society for Bone and Mineral Research (ASBMR).