MRI findings of intracranial anomalies associated with cephalocele—a case series

Introduction

Cephalocele is a relatively rare cranial dysraphism characterised by herniation of intracranial structures through the skull. Surgical management is primarily necessary where a risk of infection through communication of the lesion with the intracranial space exists, a risk of rupture, or for cosmetic purposes. Cephalocele is often associated with venous anomalies such as vertical embryonic positioning of the straight sinus, splitting of the superior sagittal sinus, vein of Galen elongation, along with tenting of the tentorium [Morioka et al. Childs Nerv Syst 25:309–315, 2009]

Patients

Here, we report four cases of cephalocele with pre-operative MRI imaging retrospectively studied, demonstrating associated venous anomalies. Three of these patients went on to have uncomplicated, corrective surgery, while one was managed conservatively.

Results

All four cases demonstrated the main venous drainage going through a persistent falcine sinus to drain into the superior sagittal sinus. Upward tenting of the tentorium was observed in three cases (cases 1, 3 and 4). Two of our cases demonstrated other venous anomalies frequently reported in the literature, namely splitting of the superior sagittal sinus and absence of the transverse sinus (case 1) and communication of the cephalocele with the superior sagittal sinus and absence of the straight sinus (case 2).

Conclusion

The association between cephalocele and venous anomalies suggests that pre-operative MRI should be mandatory for a full evaluation of a suspicious midline cranial lesion in order to evaluate the safety of corrective surgery.     

Health and wellbeing of Victorian adults with intellectual disability compared to the general Victorian population

Multiple measures of health and wellbeing of people with intellectual disability (ID) and the general Victorian population were compared using representative population level data. The sample consisted of adults with ID (N = 897) and the general Victorian population (N = 34,168) living in the state of Victoria in Australia. Proxy respondents were interviewed on behalf of people with ID, while respondents from the general Victorian population were interviewed directly. The data were weighted to reflect the age/sex/geographic distribution of the population. Results revealed that adults with ID reported higher prevalence of poor social determinants of health, behavioural risk factors, depression, diabetes, poor or fair health. A higher proportion of people with ID reported blood pressure and blood glucose checks, while a lower proportion reported cervical and breast cancer screening, compared with the general Victorian population. The survey identified areas where targeted approaches may be undertaken to improve the health outcomes of people with ID and provide an important understanding of the health and wellbeing of these Victorians.     

Key Steps in Conducting Systematic Reviews for Underpinning Clinical Practice Guidelines: Methodology of the European Association of Urology

Context

The findings of systematic reviews (SRs) and meta-analyses (MAs) are used for clinical decision making. The European Association of Urology has committed increasing resources into the development of high quality clinical guidelines based on such SRs and MAs.

COVID-19: mobilising CT as a frontline management tool

As the COVID-19 pandemic has spread across the globe, questions have arisen about the approach healthcare systems should adopt in order to optimally manage patient influx. With a focus on the impact of COVID-19 on the NHS, we describe the frontline experience of a severely affected hospital in close proximity to London. We highlight a protocol-driven approach, incorporating the use of CT in the rapid triage, assessment and cohorting of patients, in an environment where there was a lack of readily available, onsite RT-PCR testing facilities. Furthermore, the effects of the protocol on the effective streamlining of patient flow within the hospital are discussed, as are the resultant improvements in clinical management decisions within the acute care service. This model may help other healthcare systems in managing this pandemic whilst assessing their own needs and resources.     

Efficacy of Targeted Narrowband Ultraviolet B Therapy in Vitiligo

Background:

Phototherapy is one of the most effective treatment options in vitiligo. Targeted phototherapy devices are becoming more popular as they offer a lot of advantages over the conventional whole-body phototherapy units.

Aims and Objectives:

The present study was conducted to assess the efficacy and safety of a targeted narrowband ultraviolet B (NBUVB) device in vitiligo.

Materials and Methods:

A total of 40 patients of vitiligo were treated with a targeted NBUVB device twice-weekly for a maximum of 30 sessions or until 100% repigmentation, whichever was reached first. The extent of repigmentation achieved was assessed and adverse effects, if any, were also noted down.

Results:

There were 31 responders (77.5%) who achieved repigmentation ranging from 50% to 100%. The onset of repigmentation was seen as early as the 3^rd dose in some cases and by the 10^th dose in all responders. A total of 97 lesions were treated out of which 45 lesions (46.6%) achieved 90-100% repigmentation. Lesions showing 75% and 50% repigmentation were 14 and 15 in number respectively. 23 lesions failed to show any significant repigmentation at the end of 30 doses. Best response was seen on the face and neck with 20 of the 31 lesions achieving 90-100% repigmentation in this area. Duration of vitiligo was seen to have no statistically significant impact on the repigmentation achieved.

Conclusion:

Targeted NBUVB phototherapy seems to be an effective treatment option in localized vitiligo with a rapid onset of repigmentation seen as early as 2^nd week of treatment.     

Cancer of the lung: staging, radiology, surgery

Primary lung cancer is the leading cause of cancer-related deaths in industrialized countries. Despite advances in treatment, the overall 5-year survival remains poor due to the advanced stage of disease at presentation. Smoking remains the main risk factor being responsible for around 85% of all cases. The most important distinction is that between non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Surgeons primarily deal with NSCLC (SCLC is an aggressive tumour that usually presents with systemic disease). NSCLC has a number of histological subtypes.Patient evaluation aims to establish the cell type of the tumour, determine the stage of the disease, and to determine fitness for surgery. Staging of NSCLC is based on the tumour/node/metastasis (TNM) classification. Procedures used to diagnose or stage lung cancer can include chest X-ray, chest computed tomography (CT) scan, combined positron emission tomography/CT, CT or transbronchial guided needle biopsy, and mediastinoscopy amongst others. Surgery is the only established method for ‘curing’ NSCLC. However, only a quarter of patients have resectable disease at presentation. Surgical resection can be performed using a variety of procedures including lobectomy, pneumonectomy or wedge resections. The 5-year survival of patients with stage I lung cancer following surgical resection is 51-60%.     

Unexpected complication of arteriovenous fistula of the left common carotid to internal jugular vein following central venous catheterization

Incidence of inadvertent arterial puncture secondary to central venous catheter insertion is not common with an arterial puncture rate of<1%.This is due to the advancements and wide availability of ultrasound to guide its insertion.Formation of arteriovenous fistula after arterial puncture is an unexpected complication.Till date,only five cases(including this case)of acquired arteriovenous fistula formation has been described due to inadvertent common carotid puncture.The present case is a 26-year-old man sustained traumatic brain injuries,chest injuries and multiple bony fractures.During resuscitative phase,attempts at left central venous catheter via left internal jugular vein under ultrasound guidance resulted in inadvertent puncture into the left common carotid artery.Surgical neck exploration revealed that the catheter had punctured through the left internal jugular vein into the common carotid artery with formation of arteriovenous fistula.The catheter was removed successfully and common carotid artery was repaired.Postoperatively,the patient recovered and clinic visits revealed no neurological deficits.From our literature review,the safest method for removal is via endovascular and open surgical removal.The pull/push technique(direct removal with compression)is not recommended due to the high risk for stroke,bleeding and hematoma formation.     

Immune molecular profiling of whole blood drawn from a non‐human primate cardiac xenograft model treated with anti‐CD154 monoclonal antibodies

Most studies of xenografts have been carried out with complex immunosuppressive regimens to prevent immune rejection; however, such treatments may be fatal owing to unknown causes. Here, we performed immune molecular profiling following anti‐CD 154 monoclonal antibody (mA b) treatment in heterotopic abdominal cardiac xenografts from α‐1,3‐galactosyltransferase‐knockout pigs into cynomolgus monkeys to elucidate the mechanisms mediating the undesirable fatal side effects of immunosuppressive agents. Blood samples were collected from healthy monkeys as control and then at 2 days after xenograft transplantation and just before humane euthanasia; 94 genes related to the immune system were analyzed. The basic immunosuppressive regimen included cobra venom factor, anti‐thymocyte globulin, and rituximab, with and without anti‐CD 154 mA bs. The maintenance therapy was followed with tacrolimus, MMF , and methylprednisolone. The number of upregulated genes was initially decreased on Day 2 (?/+ anti‐CD 154 mA b, 22/13) and then increased before euthanasia in recipients treated with anti‐CD 154 mA bs (?/+ anti‐CD 154 mA b, 30/37). The number of downregulated genes was not affected by anti‐CD 154 mA b treatment. Additionally, the number of upregulated genes increased over time for both groups. Interestingly, treatment with anti‐CD 154 mA bs upregulated coagulation inducers (CCL 2/IL 6 ) before euthanasia. In conclusion, immunosuppressive regimens used for cardiac xenografting affected upregulation of 6 inflammation genes (CXCL 10, MPO , MYD 88, NLRP 3, TNF α, and TLR 1) and downregulation of 8 genes (CCR 4 , CCR 6 , CD 40 , CXCR 3 , FOXP 3 , GATA 3 , STAT 4 , and TBX21 ).     

Changing the paradigm of organ utilization from PHS increased‐risk donors: an opportunity whose time has come?

Approximately 8–11% of all organ donors are classified by Public Health Service (PHS) as increased‐risk. The proportion of PHS increased‐risk donors is on the rise. At the University of Washington Medical Center, in 2014, the proportion of transplants from PHS increased‐risk donors was 28% of liver transplants and 23% of kidney transplants. Nationally, transplant providers have been reluctant to use organs from PHS increased‐risk donors because of concern for transmission of HIV, HCV, or HBV. There is also patient apprehension when these organs are being offered, and thus the discard rate of these otherwise good quality organs is high. Because of the organ shortage, preventing underutilization of such organs is essential. We provide data and considerations that should be used to guide the use of organs from PHS increased‐risk donors.