Showing papers by "Lincoln Hospital published in 2019"

Antibody-drug conjugates in clinical trials for lymphoid malignancies and multiple myeloma

Abstract: Antibody-drug conjugates (ADC) represent a distinct family of chemoimmunotherapy agents. ADCs are composed of monoclonal antibodies conjugated to cytotoxic payloads via specialized chemical linkers. ADCs therefore combine the immune therapy with targeted chemotherapy. Due to the distinct biomarkers associated with lymphocytes and plasma cells, ADCs have emerged as a promising treatment option for lymphoid malignancies and multiple myeloma. Several ADCs have been approved for clinical applications: brentuximab vedotin, inotuzumab ozogamicin, moxetumomab pasudotox, and polatuzumab vedotin. More novel ADCs are under clinical development. In this article, we summarized the general principles for ADC design, and updated novel ADCs under various stages of clinical trials for lymphoid malignancies and multiple myeloma.

Vitamin C, Hydrocortisone, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Analysis of Real-World Application

Abstract: A recent study suggested mortality benefits using vitamin C, hydrocortisone, and thiamine combination therapy (triple therapy) in addition to standard care in patients with severe sepsis and septic shock. In order to further evaluate the effects of triple therapy in real-world clinical practice, we conducted a retrospective observational cohort study at an academic tertiary care hospital. A total of 94 patients (47 in triple therapy group and 47 in standard care group) were included in the analysis. Baseline characteristics in both groups were well-matched. No significant difference in the primary outcome, hospital mortality, was seen between triple therapy and standard care groups (40.4% vs. 40.4%; p = 1.000). In addition, there were no significant differences in secondary outcomes, including intensive care unit (ICU) mortality, requirement for renal replacement therapy for acute kidney injury, ICU length of stay, hospital length of stay, and time to vasopressor independence. When compared to standard care, triple therapy did not improve hospital or ICU mortality in patients with septic shock. A randomized controlled trial evaluating the effects of triple therapy is necessary prior to implementing vitamin C, hydrocortisone, and thiamine combination therapy as a standard of care in patients with septic shock.

Inter-observer Variability in the American College of Radiology Thyroid Imaging Reporting and Data System: In-Depth Analysis and Areas for Improvement.

Abstract: The American College of Radiology (ACR) introduced a new standardized system for management of thyroid nodules, the Thyroid Imaging Reporting and Data System (TI-RADS). The purpose of this retrospective study is to evaluate the inter-observer variability in applying TI-RADS in clinical practice without prior dedicated training. We evaluated a total of 180 nodules constituting all consecutive thyroid aspirations performed in the radiology department between January 1, 2014 and June 30, 2014, with exclusion of histologically inadequate samples. Four radiologists, blinded to each other's evaluation and to final pathology results, evaluated all of the nodules based on the TI-RADS lexicon. TI-RADS score and management recommendations were then deduced from the inputted features. Statistical analysis was performed to determine inter-observer agreement among all readers, as well as between each two readers, in all TI-RADS sonographic features and for recommended management per TI-RADS score with multi-user Cohen's κ (Light's κ) and percentage agreement using R. There was fair-to-moderate inter-observer agreement in nodule composition (two-reader κ range: 0.327-0.533) and presence of calcifications (κ range: 0.229-0.527), but poor-to-fair agreement in echogenicity (κ range: 0.141-0.355), shape (κ range: 0.0729-0.513) and margins (κ range: 0.176-0.283). There was fair inter-observer agreement regarding management recommendations (κ range: 0.242-0.359).

Gemtuzumab ozogamicin and novel antibody-drug conjugates in clinical trials for acute myeloid leukemia.

Abstract: Targeted agents are increasingly used for the therapy of acute myeloid leukemia (AML). Gemtuzumab ozogamicin (GO) is the first antibody-drug conjugate (ADC) approved for induction therapy of AML. When used in fractionated doses, GO combined with the conventional cytarabine/anthracycline-based induction chemotherapy significantly improves the outcome of previously untreated AML patients. Single-agent GO is effective and safe for AML patient ineligible for intensive chemotherapy. Multiple combination regimens incorporating GO have also been recommended as potential alternative options. In addition, several novel ADCs targeting CD33, CD123 and CLL-1 are currently undergoing preclinical or early clinical investigations. In this review, we summarized the efficacy and limitations of GO as well as novel ADCs for adult AML patients.

New Frontiers in IVF: mtDNA and autologous germline mitochondrial energy transfer

Abstract: Many infertility specialists support the existence of a relationship between the levels of mitochondrial DNA and the quality of the blastocysts. Despite the extensive use of pre-implantation genetic testing for aneuploidy, a significant percentage of euploid embryos do not implant even though the endometrium is normal. Mitochondrial DNA may be used as a new test in evaluating embryonic vitality. Ovarian aging leads to a decrease in the quantity and quality of oocytes and aged oocytes have a reduced number of mitochondria. Mitochondria are the energy factories of the cells and their lacked could leads to lower fertilization rates and poor embryonic development. Various strategies have been tested to increase the mitochondria quantity and thus improve the quality of oocytes used in in vitro fertilization. Results of ovarian rejuvenation techniques such as autologous mitochondrial transplantation have been controversial. In this review, we describe the state of the art concerning the use of mitochondrial DNA and autologous mitochondrial transplantation as new possibilities to increase success in vitro fertilization.

A randomized, double-blinded trial comparing the effectiveness of tranexamic acid and epsilon-aminocaproic acid in reducing bleeding and transfusion in cardiac surgery.

Abstract: Objectives: To compare the effectiveness of epsilon aminocaproic acid (EACA) to tranexamic acid (TA) in reducing blood loss and transfusion requirements in patients undergone cardiac surgery under cardiopulmonary bypass. Design: Randomized, double blinded study. Outcome variables collected included; baseline demographic characteristics, type of surgery, amount of 24 hour chest tube drainage, amount of 24 hour blood products administered, 30 day mortality and morbidity and length of stay. We analyzed the data using parametric and non-parametric tests as appropriate. Setting: Single center tertiary-care university hospital setting. Participants: 114 patients who had undergone cardiac surgery under cardiopulmonary bypass. Interventions: Standard dose of intra-operative EACA or TA was compared in patients undergone cardiac surgery under cardiopulmonary bypass. Results: There was no statistically significant difference between groups when analyzing chest tube drainage. However, there was a significant difference in the administration of any transfusion (PRBC's, FFP, platelets) intra-operatively to 24 hours postoperatively, with less transfusion in patients receiving EACA compared to TA (25% vs. 44.8%, respectively P = 0.027). Additionally, there was no significant difference in terms of adverse events during the one month follow up period. Conclusion: The findings of this study suggest that EACA and TA have similar effects on chest tube drainage but EACA is associated with fewer transfusions in CABG alone surgeries. Our results suggest that EACA can be used in a similar fashion to TA which may result in a cost and morbidity advantage.

Qualitative Study of Knowledge, Perception, and Behavior Related to Hypertension and Cardiovascular Disease Risk Reduction Among Hypertensive African-Americans in Urban Inner City of South Bronx, New York.

Abstract: To study the knowledge, perception, and behaviors among hypertensive African-Americans in South Bronx, New York, to elucidate any gaps that could explain their poor blood pressure control. Cross-sectional qualitative study on African-American participants with essential hypertension, on single or combined oral antihypertensive regimen. Three focus groups were presented with open-ended questions on topics including cardiovascular disease knowledge, perception, and behaviors. A total of 18 data collection tools were used. Concepts formulated were categorized into dominant themes. A sample size of 21 participants was attained based on the saturation point related to emerging common themes. Six dominant themes identified were unhealthy diet, stress, patient-physician relationship, medication non-compliance, decreased physical activity, and hypertension complications. The most dominant was unhealthy diet with self-identified barriers such as poor food selection, family tradition, economical cost, will-power, food taste, and accessibility to healthier food. Regarding medication adherence, participants recognized trust was a determining factor that has been negatively reinforced by previous experiences with their healthcare providers especially when they were not perceived as knowledgeable. Participants have also felt they have been influenced by historic events in their health decision-making process. The South Bronx African-American population has some feelings that are valid and not simply misconceptions. Some of them are historically related, gaps in knowledge influenced by culture and traditions, and barriers to healthy behaviors enhanced by economic status, lack of will-power, physical limitations, and stress from daily living. A physician partnership with this African-American community to improve trust, raise awareness, facilitate, and change in behavior that could help address blood pressure control and prevent cardiovascular disease.

Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and Routine Complete Blood Count Components in HELLP Syndrome: A Matched Case Control Study.

Abstract: Background and objective: Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are new readily available inflammatory markers that have been analyzed in pregnancy-induced hypertensive disorders such as preeclampsia. Studies on the NLR/PLR ratio in hemolysis, elevated liver enzymes, low-platelet count (HELLP) syndrome are limited in the current literature. We compared NLR/PLR and other complete blood count (CBC) components between women with HELLP syndrome and women with healthy pregnancies. Methods: We conducted a retrospective matched case–control study at a tertiary care hospital in NY (USA) in the time frame between January 2016 and December 2018. The study compared pregnant women with HELLP syndrome (cases) to women with healthy pregnancies in the third trimester (controls), matched by age, body mass index (BMI), parity, and race. Patient with preeclampsia, infection, and fever were excluded. Venous blood samples were obtained as part of the routine work-up at admission for delivery, which included a CBC. The main outcomes were NLR and PLR. The secondary outcomes were hemoglobin, red cell distribution width (RDW), platelet count, mean platelet volume (MPV), neutrophils, lymphocytes. Results: There were 14 patients in each group. They were matched by age, race, BMI, and parity. NLR (5.8 vs. 3.6, p-value = 0.002) and neutrophil count (10.7 vs. 6.8, p-value = 0.001) were higher in women with HELLP compared to controls. PLR (34 vs. 130.2, p-value < 0.001) and platelet count (71 vs. 223, p-value < 0.001) were lower in the study group compared to controls. Conclusions: NLR was higher, and PLR was lower in women with HELLP syndrome. These inflammatory markers can be incorporated into the diagnostic algorithm for HELLP syndrome. Future studies are needed to evaluate their ability to predict HELLP syndrome.

Contribution of Epithelial Cells to Defense Mechanisms in the Human Vagina

Abstract: The vaginal milieu in women differs from that of other mammals, including non-human primates, in composition of secretions, the endogenous microbiota, and level of acidity. These changes apparently reflect evolutionary variations that maximized productive responses to a uniquely human vaginal environment. This review will highlight recent findings on properties of human vaginal epithelial cells that contribute to maintenance of a healthy vaginal environment. Vaginal epithelial cells are responsive to the composition of the vaginal microbiome even in women who are in apparently good health and do not exhibit any adverse physical symptoms. This is especially important during pregnancy when immune defenses are modified and an effective epithelial cell-derived anti-microbial activity is essential to prevent the migration to the uterus of bacteria potentially harmful to pregnancy progression. When Lactobacillus crispatus numerically predominates in the vagina, epithelial cell activity is low. Conversely, predominance of Lactobacillus iners, Gardnerella vaginalis, or other non-Lactobacilli evokes production and release of a large variety of compounds to minimize the potentially negative consequences of an altered microbiome. The extent of autophagy in vaginal epithelial cells, a basic process that functions to maintain intracellular homeostasis and engulf microbial invaders, is also sensitive to the external microbial environment Vaginal epithelial cells bind and release norepinephrine and upregulate their anti-microbial activity in response to external stress. Vaginal epithelial cells in women are responsive to local conditions that are unique to humans and, thereby, contribute to maintenance of a healthy milieu.

Body of Evidence in Favor of Adopting 130/80 mm Hg as New Blood Pressure Cut-Off for All the Hypertensive Disorders of Pregnancy.

Abstract: The American College of Cardiology/American Heart Association (ACC/AHA) updated its guideline redefining the classification of hypertension and the blood pressure cut-off in 2017. The current cut-offs for stage 1 hypertension of 130 mm Hg systolic blood pressure or 80 mm Hg diastolic blood pressure replace the previous cut-offs of 140 mm Hg systolic blood pressure or 90 mm Hg diastolic blood pressure which were based on the ACC/AHA guidelines from 1988. However, the blood pressure cut-off for the obstetric population still remains as 140/90 mm Hg despite the scarcity of evidence for it. Recent American College of Obstetricians and Gynecologists (ACOG) bulletins for pregnant women have not reflected the new ACC/AHA change of guideline. We reviewed a mounting body of evidence prompting the implementation of the new ACC/AHA guidelines for the obstetric population. These studies examined maternal and fetal outcomes applying the new ACC/AHA guidelines during antepartum or postpartum care.

Effectiveness of Shared Decision-Making for Elderly Depressed Minority Primary Care Patients.

Abstract: Objective: The authors assessed the impact of a shared decision-making (SDM) intervention among elderly depressed minority primary care patients not currently receiving treatment. Methods: A total of 202 English and Spanish-speaking primary care participants aged 65 and older who scored positive on the Patient Health Questionnaire-9 (≥10) were randomized at the physician level to receive a brief SDM intervention or usual care (UC). Primary analyses focused on patient adherence to either psychotherapy or antidepressant medication, and reduction in depression severity (Hamilton Depression Rating Scale) over 12 weeks. Results: Patients randomized to physicians in the SDM condition were significantly more likely than patients of physicians randomized to UC to receive a mental health evaluation or initiate some form of treatment (39% versus 21%), and to adhere to psychotherapy visits over 12 weeks. There were no differences between groups in adherence to antidepressant medication or in reduction of depressive symptoms. Conclusion: Among untreated elderly depressed minority patients from an inner-city municipal hospital, a brief SDM intervention was associated with greater initiation and adherence to psychotherapy. However, low treatment adherence rates across both groups and the intervention's lack of impact on clinical outcomes highlight the need to provide focused and accessible mental health services to patients choosing active treatments.

Influence of assisted reproductive technologies on maternal and neonatal outcomes in early preterm deliveries.

Abstract: Introduction Compared to spontaneous conception (SC), pregnancies conceived through assisted reproductive technologies (ART) carry worse pregnancy and neonatal outcomes. Evidences focused on preterm births are limited. Early preterm delivery is a critical situation for medical management and parental counselling. The aim of this study was to analyze if ART procedures influenced pregnancy and neonatal outcomes in singleton pregnancies with early preterm delivery. Material and methods This was a retrospective case control study. The population consisted of all consecutive early preterm deliveries occurred at Careggi University Hospital in Florence (Italy) between 2010 and 2017. Cases were considered patients who conceived though ART, including intra cytoplasmic sperm injection (ICSI), in vitro fertilization and embryo transfer (IVF-ET), intra uterine insemination (IUI) and ovarian stimulation. Controls were patients who conceived in the natural way. Main outcomes of the study were: birth weight, umbilical artery pH, Apgar score at 1 and 5 min, gestational age at delivery and mode of delivery. Secondary outcomes were: spontaneous preterm labor initiation, gestational diabetes mellitus, intrauterine growth restriction (IUGR), cholestasis of pregnancy, intra uterine fetal demise (IUFD), placenta previa, fetal malformations, pregnancy induced hypertensive (PIH) disorders (gestational hypertension, preeclampsia and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome) and postpartum hysterectomy. Shapiro-Wilk test was used to check the normality of the data; Mann-Whitney test was used to compare two continuous variables not-normally distributed. Multiple and binomial logistic regression analyses were used to adjust the results of the statistical analysis for potential confounding factors. The analysis for the main outcomes was performed for all deliveries and then repeated for spontaneous deliveries, separately. Results Seventy-one patients had ART and 640 SC. We found no differences in birthweight, umbilical artery pH, Apgar at 1 and 5 min and gestational age at delivery between ART and SC groups. C-section rate, placenta previa and PIH disorders were higher in the ART group. The higher prevalence of C-sections in the ART group was not statistically significant after adjusting for age and parity in the whole population but resulted significantly different when analyzing the subgroup of patients with spontaneous initiation of labor. Conclusions Fetal outcomes seem to be equal between ART and SC in early preterm neonates ; C-section rate and pregnancy complications such as placenta previa and PIH disorders seem to be higher in the ART group. These information should be part of the family counselling in these cases. We suggest that clinicians, after management of preterm delivery had been properly addressed, should not apply different management in ART compared to SC pregnancies.

One-Year Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement for Stenotic Bicuspid versus Tricuspid Aortic Valves: A Meta-Analysis and Meta-Regression.

Abstract: Objective. To assess 1-year mortality after transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic stenosis (AS). Background. Clinical trials have proven the beneficial effect of TAVR on mortality in patients with tricuspid AS. Individuals with bicuspid AS were excluded from these trials. Methods. A meta-analysis using literature search from the Cochrane, PubMed, ClinicalTrials, SCOPUS, and EMBASE databases was conducted to determine the effect of TAVR on 1-year mortality in patients with bicuspid AS. Short-term outcomes that could potentially impact one-year mortality were analyzed. Results. After evaluating 380 potential articles, 5 observational studies were selected. A total of 3890 patients treated with TAVR were included: 721 had bicuspid and 3,169 had tricuspid AS. No statistically significant difference between the baseline characteristics of the two groups of patients was seen outside of mean aortic gradient. Our primary endpoint of one-year all-cause mortality revealed 85 deaths in 719 patients (11.82%) with bicuspid AS compared to 467 deaths in 3100 patients (15.06%) with tricuspid AS, with no difference between both groups [relative risk (RR) 1.03; 95% CI 0.70-1.51]. Patients with bicuspid AS were associated with a decrease in device success (RR 0.62; 95% CI 0.45-0.84) and an increase in moderate-to-severe prosthetic valve regurgitation (RR 1.55; 95% CI 1.07-2.22) after TAVR compared to patients with tricuspid AS. The effect of meta-regression coefficients on one-year all-cause mortality was not statistically significant for any patient baseline characteristics. Conclusion. When comparing TAVR procedure in tricuspid AS versus bicuspid AS, there was no difference noted in one-year all-cause mortality.

Effective Dosage of Oral Vancomycin in Treatment for Initial Episode of Clostridioides difficile Infection: A Systematic Review and Meta-Analysis.

Abstract: Background: Oral vancomycin is a first line treatment for an initial episode of Clostridioides difficile infection. However, the comparative efficacy of different dosing regimens is lacking evidence in the current literature. Methods: We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. from inception to May 2019. Only articles published in English are reviewed. This meta-analysis compares the effects of low dose oral vancomycin (<2 g per day) versus high dose vancomycin (2 g per day) for treatment of initial Clostridioides difficile infection. Results: One randomized controlled trial and two retrospective cohort studies are included. A total of 137 patients are identified, 53 of which were treated with low dose oral vancomycin (39%) and 84 with high dose oral vancomycin (61%). There is no significant reduction in recurrence rates with high dose vancomycin compared to low dose vancomycin for treating initial episodes of non-fulminant Clostridioides difficile infection ((odds ratio (OR) 2.058, 95%, confidence interval (CI): 0.653 to 6.489). Conclusions: Based on limited data in the literature, low dose vancomycin is no different than high dose vancomycin for treatment of an initial episode of Clostridioides difficile infection in terms of recurrence rate. Additional large clinical trials comparing the different dosages of vancomycin in initial Clostridioides difficile infection are warranted.

Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio and Complete Blood Count Components in the First Trimester Do Not Predict HELLP Syndrome.

Abstract: Background and Objectives: Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), mean platelet volume (MPV), and other components of the routine complete blood count (CBC) were found to be sensitive biomarkers of preeclampsia and other inflammatory obstetric conditions in previous studies, with conflicting results. We speculated that the same associations existed with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome in the first trimester of pregnancy. Materials and Methods: We conducted a retrospective case-control study at a tertiary care hospital in NY (USA), in the time frame between January 2016 and December 2018. Our population consisted of pregnant women in the first trimester: We compared patients with HELLP syndrome (cases) with healthy patients (controls) matched by age, body mass index (BMI), parity, and race. Patients with preeclampsia, infection, and fever were excluded. Venous blood samples were obtained as part of the routine work-up during the first prenatal visit in the first trimester, which includes a CBC. The main outcomes were NLR and PLR, and the secondary outcomes were hemoglobin, RDW, platelet count, MPV, neutrophils, and lymphocytes. Results: There were 10 patients in each group (Table 1). There were no differences in NLR and PLR levels and other CBC components between the two groups (Table 2). Conclusions: In our study NLR, PLR, and other CBC components did not predict HELLP syndrome. We speculate that HELLP syndrome has a sudden increase of tissue inflammation in the third trimester that is not manifested during the early phases of placentation. Larger studies are needed to evaluate the true ability of NLR, PLR, and CBC components to predict HELLP syndrome in the first trimester.

Glycogen Storage Disease, Type II (Pompe Disease)

Abstract: Glycogen storage disease type II (GSD2, Pompe Disease) is a recessive metabolic disorder, creating glycogen deposits inside lysosomes within the muscular tissue.This disease is either classified as early (infantile, classic) or late-onset (non-classic). Early-onset has a severe presentation and is likely to feature a fatal outcome, should prompt treatment not be available. A common cause of lethality for both onsets is respiratory insufficiency, which manifests at different ages in late-onset. Another important cause of lethality in infantile-onset is left ventricular outflow obstruction.Preventive treatment consists of enzyme replacement therapy (alglucosidase alfa), maintaining an updated immunization schedule, and respiratory syncytial virus (RSV) prophylaxis. Adults developing signs of respiratory insufficiency can benefit from respiratory exercises or assisted mechanical ventilation, which may also be convenient for children.

Case report of congenital asplenia presenting with Haemophilus influenzae type a (Hia) sepsis: an emerging pediatric infection in Minnesota

Abstract: In the pre-vaccine era, invasive disease with Haemophilus influenzae, type b (Hib) commonly presented with osteoarticular involvement. Haemophilus influenzae, type a (Hia) sepsis is a rare but emerging problem in recent years. Here, we report a case of sepsis with concomitant osteoarthritis due to Hia that was the presenting infectious disease manifestation of isolated asplenia in a young child. This unique observation adds to our understanding of sepsis and asplenia in children. A five-year-old girl developed acute Hia bacteremia and sepsis. The patient developed arthritis shortly after onset of septic shock. Arthrocentesis was culture-negative, but given the difficulty differentiating between septic and reactive arthritis, prolonged antibiotic administration was provided for presumed osteoarticular infection, and the patient had an uneventful recovery. The finding of Howell-Jolly bodies on blood smear at the time of presentation prompted an evaluation that revealed isolated congenital asplenia. Evaluation for known genetic causes of asplenia was unrevealing. Investigation by the Minnesota Department of Health revealed an emergence of Hia infections over the past 5 years, particularly in children with an American Indian background. Hia is an important pathogen in the differential diagnosis of invasive bacterial infections in children and shares overlap in clinical presentation and pathogenesis with Hib. Invasive Hia disease can be a presenting manifestation of asplenia in children. Hia is an emerging pathogen in American Indian children.

Elbow Fractures Overview

Abstract: The most common type of fracture in the pediatric population is elbow fractures. Most commonly, individuals fall on their outstretched hand. Prompt assessment and management of elbow fractures are critical, as these fractures carry the risk of neurovascular compromise. The following are the types of elbow fractures in pediatrics: Supracondylar Fractures This type of fracture involves the distal humerus just above the elbow. It is the most common type of elbow fracture and accounts for approximately 60% of all elbow fractures. It is considered an injury of the immature skeleton and occurs in young children between 5 to 10 years of age. Based on the mechanism of injury and the displacement of the distal fragment, professionals classify these as either extension or flexion type fractures.In an extension type of fracture, which happens more than 95% cases, the elbow displaces posteriorly. The typical mechanism is falling on an outstretched hand with the elbow in full extension. An example is falling from monkey bars. Beware that a nondisplaced fracture may be subtle and may only be recognized by one of the following: Posterior fat pad sign Anterior sail sign Disruption of the anterior humeral line Radiographically, these fractures are classified into three types: Type I: minimal or no displacement Type II: displaced fracture, posterior cortex intact Type III: totally displaced fracture, anterior and posterior cortices disrupted In a flexion type fracture that happens in less than 5% of cases, the elbow is displaced anteriorly. The typical mechanism is when a direct anterior force is applied against a flexed elbow, which causes anterior displacement of the distal fragment. With the displacement of the fragment, the periosteum tears posteriorly. Since the mechanism is a direct force, flexion type fractures are often open. Type I fracture: non-displaced or minimally displaced Type II fracture: incomplete fracture; anterior cortex is intact Type III fracture: completely displaced; distal fragment migrates proximally and anteriorly One of the most serious complications is neurovascular injury following the fracture, as the brachial artery and median nerve are located close to the site of fracture and can be easily compromised. Gartland Classification Supracondylar fractures can be classified depending on the degree of displacement: Gartland Type 1 Fracture: Minimally displaced or occult fracture. The fracture is difficult to see on x-rays. The anterior humeral line still intersects the anterior half of the capitellum. The only visible sign on an x-ray will be a positive fat pad sign. Gartland Type 2 Fracture: Fracture that is displaced more posteriorly, but the posterior cortex remains intact. Gartland Type 3 Fracture: Completely displaced fracture with cortical disruption. Posteromedial displacement is more common happening in 75% of cases compared to posterolateral displacement which occurs in 25% of cases. Lateral Condyle Fractures These types of fracture are the second most common type of elbow fracture in children and account for 15% to 20% of all elbow fractures. This fracture involves the lateral condyle of the distal humerus, which is the outer bony prominence of the elbow. The peak age for the occurrence of lateral condyle fractures is four to ten years old. Most commonly, these are Salter-Harris type IV ( a fracture that transects the metaphysis, physis, and epiphysis) involving the lateral condyle.Two types of classifications are used to describe lateral condyle fractures: Milch classification Milch 1: Less common type. Fracture line traverses laterally to the trochlear groove. Elbow is stable. Milch II: More common type. Fracture passes through the trochlear groove. Elbow is unstable. Displacement Classification Type 1: Displacement less than 2 mm Type 2: more than 2 mm but less than 4 mm displacement. Fragment is close to the humerus Type 3: Wide displacement, the articular surface is disrupted. Medial Epicondyle Fractures These fractures are the third most common type of elbow fracture in children. It is an extra-articular fracture. It involves fracture of the medial epicondyle apophysis, which is located on the posteromedial aspect of the elbow. It commonly occurs in early adolescence, between the ages of nine to 14 years of age. It is more common in boys and occurs during athletic activities such as football, baseball, or gymnastics. The common mechanisms of injury are a posterior elbow dislocation and repeated valgus stress. An example is throwing a baseball repeatedly. One term for this is “little league elbow.”Common presentation is medial elbow pain, tenderness over the medial epicondyle, and valgus instability. Radial Head and Neck Fractures These fractures comprise about 1% to 5% of all pediatric elbow fractures. Most commonly these are Salter-Harris type II fractures that transect the physis and extend into the metaphysis for a short distance. This usually occurs between the ages of nine to ten years. Olecranon Fractures Olecranon fractures are uncommon in children. These are mostly associated with radial head and neck fractures.

Madelung's Disease Leading to Presenile Dementia in a Non-alcoholic Patient.

Abstract: Introduction: Madelung’s disease (MD) is a rare disorder of unknown etiology defined as the presence of multiple and symmetrical fatty accumulations most commonly involving the upper trunk, neck, and head. Excessive alcohol ingestion has been linked traditionally to the pathogenesis of the disease. The central and peripheral nervous system could both be affected. Presenile dementia, without alcohol abuse, has been rarely reported in the literature as a complication. Aim: The aim of this case report is to highlight that multiple symmetric lipomatosis can be complicated by presenile dementia even if the patient is non-alcoholic. Case Report: This case report describes a middle age non-alcoholic woman who presented for increased forgetfulness. Brain CT scan showed cerebral and cerebellar atrophy inappropriate for her age. Despite being started on anticholinergic drug, her MMSE decreased 3 points in 1 year. Conclusion: Clinicians should consider early onset dementia as a potential complication of Madelung’s disease even in patients with no preceding history of alcoholism. A brain MRI and MMSE can aid with identifying such a complication.

Acute Compartment Syndrome

Abstract: Acute compartment syndrome occurs when there is increased pressure within a closed osteofascial compartment, resulting in impaired local circulation. Acute compartment syndrome is considered a surgical emergency since, without proper treatment, it can lead to ischemia and eventually necrosis. Generally, acute compartment syndrome is considered a clinical diagnosis. However, intracompartmental pressure (ICP) > 30 mmHg can be used as a threshold to aid in diagnosis. However, a single normal ICP reading does not exclude acute compartment syndrome. Fascia is a thin, inelastic sheet of connective tissue that surrounds muscle compartments and limits the capacity for rapid expansion. In the leg, there are four muscle compartments: anterior, lateral, deep posterior, and superficial posterior. The anterior compartment of the leg is the most common location for compartment syndrome. This compartment contains the extensor muscles of the toes, the tibialis anterior muscle, the deep peroneal nerve, and the tibial artery. Other locations in which acute compartment syndrome is seen include the forearm, thigh, buttock, shoulder, hand, and foot. It can also be seen in the abdomen, but more commonly, it presents in the limbs.

A spotlight on alirocumab in high cardiovascular risk patients with type 2 diabetes and mixed dyslipidemia: a review on the emerging data

Abstract: Diabetes is a significant and independent risk factor for atherosclerotic cardiovascular disease (ASCVD), leading to morbidity and mortality among this population. The prevention of macrovascular complications, such as CVD, peripheral arterial disease, and cerebrovascular accident, in patients with diabetes is obtained through multifactorial risk reduction, including mixed dyslipidemia management and adequate glycemic control. For patients with diabetes, it is crucial to initiate adequate dyslipidemia therapy to achieve recommended low-density lipoprotein cholesterol (LDL-C) goal of <70 mg/dL or target non-high-density lipoprotein goal of <100 mg/dL. Lipid-lowering therapies (LLTs), such as statins and ezetimibe, are the cornerstone for plasma LDL-C lowering; however, individuals with diabetes are often unable to achieve target lipid goals with these therapies alone and frequently require additional treatments. A new class of LLTs, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, provides a novel approach to lowering lipids in persons with high CV risk, such as those with diabetes. The clinical data presented in this review indicate the potential benefits of alirocumab in patients with diabetes and its value as a treatment option in patients with diabetic dyslipidemia with no significant safety concerns.

Cyanotic Heart Disease

Abstract: Congenital heart disease (CHD) are structural abnormalities of the heart or intrathoracic great vessels occurring during fetal development. CHD is the most common type of birth defect and the leading cause of death in children with congenital malformations. CHD can be subdivided in non-cyanotic CHD and cyanotic CHD which is also called critical congenital heart disease (CCHD). CCHD can be further classified into 3 different type of lesions: right heart obstructive lesions, left heart obstructive lesions, and mixing lesions.

A Mucinous Cystic Neoplasm Originating from the Gallbladder: A Case Report and Literature Review

Abstract: Introduction Mucinous cystic neoplasms of the gallbladder are extremely rare, benign, unilocular or multilocular cystic tumors that contain septations. Mucinous cystadenoma, a subtype of mucinous cystic neoplasm, is defined as epithelial cystic proliferations composed of cells that contain intracytoplasmic mucin. Case presentation A 70-year-old African American woman was admitted to the hospital because of progressive lower back pain and inability to walk. She was scheduled for a kyphoplasty. However, the day before surgery, she reported severe abdominal pain radiating to her right shoulder. On further workup, results of abdominal ultrasonography revealed a cystic mass in the lumen of the gallbladder. The kyphoplasty was postponed and a laparoscopic cholecystectomy was performed. Pathologic evaluation of the gallbladder revealed a multiloculated mucinous cystic neoplasm. Discussion Mucinous cystadenoma of the gallbladder account for 0.02% of the total number of cases in the hepatobiliary system. They are more frequently seen in middle-age women with a mean age at presentation of 45 years. Symptoms vary depending on the location of the tumor, but it typically presents as acute or chronic right upper quadrant pain, epigastric pain, and nausea and vomiting. The multilocular form is more common than unilocular. The cystic lesions can be filled with serous, hemorrhagic, mucinous, or mixed fluids. Clinicians should be suspicious of mucinous cystadenoma of the gallbladder when common gallbladder disease is excluded because malignant features can be present in the lesion.