We determined whether stone attenuation can predict stone fragmentation after shock wave lithotripsy in the pediatric population. Previous studies show that preoperative attenuation in HU on noncontrast computerized tomography predicts shock wave lithotripsy success. To our knowledge study of this parameter in the pediatric population has been lacking to date.We performed a multi-institutional review of the records of 53 pediatric patients 1 to 18 years old who underwent shock wave lithotripsy for 3.8 to 36.0 mm renal calculi. Stone size, average skin-to-stone distance and attenuation value were determined by bone windows on preoperative noncontrast computerized tomography. Success was defined as radiographically stone-free status at 2 to 12-week followup after a single lithotripsy session without the need for further sessions or ancillary procedures.After lithotripsy 33 patients (62%) were stone-free and 20 had incomplete fragmentation or required additional procedures. Mean ± SD stone attenuation in successfully treated patients vs those with incomplete fragmentation was 710 ± 294 vs 994 ± 379 HU (p = 0.007). Logistical regression analysis revealed that only attenuation in HU was a significant predictor of success. When patients were stratified into 2 groups (less than 1,000 and 1,000 HU or greater), the shock wave lithotripsy success rate was 77% and 33%, respectively (p <0.003).Stone attenuation less than 1,000 HU is a significant predictor of shock wave lithotripsy success in the pediatric population. This finding suggests that attenuation values have a similar predictive value in the pediatric population as that previously reported in the adult population.
Frontotemporal dementia (FTD) is a type of dementia causing degeneration in the frontal and temporal lobes. Patients with FTD often show signs or symptoms of environmental dependency. We investigated patterns of television watching in patients with FTD to discern its frequency in patients with FTD, and to possibly find evidence of its relation to other environmental dependency symptoms found in FTD.C We recruited 40 patients diagnosed with FTD and 48 Alzheimer's disease patients as controls. Patients’ caregivers were given a structured interview based on a questionnaire regarding patients’ television watching patterns and other behavioral symptoms. More patients with FTD than AD watched more TV compared to before disease onset. Compared to AD patients, FTD patients watched more hours of TV per day, and watched more hours of TV compared to before disease onset. There were more FTD patients who exhibited ‘excessive - more than 12 hours/day’ TV watching. More than half of the FTD patients showed signs of environmental dependency. Patients with more signs of environmental dependency watched more hours of TV. Forest plots of rank with 95% CI from bootstrap between cognitvely normal subjects that are PiB negative and those that are PiB positive. The second axis show AUROC values.
Abstract Understanding the genetic determinants of brain aging is important because advanced biological age of the brain is a risk factor for Alzheimer’s disease (AD). Single-nucleotide polymorphisms (SNPs) are genetic variations with effects on brain aging; mapping their influence on brain structure can elucidate the genetic correlates of AD. We adopted an information theoretic approach to this by computing the mutual information (MI) between (A) 22 AD-risk SNPs and (B) the MRI intensities of the cortex in 6,000 UK Biobank participants (~50% females) aged 54 to 84 years. These cortex-wide calculations quantified how SNPs impact brain structure. As expected, the APOE-ε4 allele, the strongest genetic risk factor for AD, exhibited significantly (p < 0.025) higher MI with MRI intensity, when compared to the average MI expected for a null distribution model, in the medial parietal lobe, pars orbitalis, and left inferior occipital lobe, three brain structures responsible for memory recall, language processing, and visual perception. These findings reflect the memory loss, decreased speech, and reduced peripheral vision experienced by individuals with AD. The ABCA7 allele, a risk factor for late- onset AD, had significantly (p < 0.025) higher MI in the inferior temporal sulcus and angular gyrus. These structures are responsible for visual recognition and attention, two functions that are severely impaired by AD. Other findings reveal similar relationships between AD-risk SNPs and brain structure. Our findings illustrate how mapping the MI between MRI intensities and SNPs provides insight into genetic influences on brain structures linked to AD symptoms.
Resting state functional magnetic resonance imaging (rsfMRI) provides researchers and clinicians with a powerful tool to examine functional connectivity across large-scale brain networks, with ever-increasing applications to the study of neurological disorders, such as traumatic brain injury (TBI). While rsfMRI holds unparalleled promise in systems neurosciences, its acquisition and analytical methodology across research groups is variable, resulting in a literature that is challenging to integrate and interpret. The focus of this narrative review is to address the primary methodological issues including investigator decision points in the application of rsfMRI to study the consequences of TBI. As part of the ENIGMA Brain Injury working group, we have collaborated to identify a minimum set of recommendations that are designed to produce results that are reliable, harmonizable, and reproducible for the TBI imaging research community. Part one of this review provides the results of a literature search of current rsfMRI studies of TBI, highlighting key design considerations and data processing pipelines. Part two outlines seven data acquisition, processing, and analysis recommendations with the goal of maximizing study reliability and between-site comparability, while preserving investigator autonomy. Part three summarizes new directions and opportunities for future rsfMRI studies in TBI patients. The goal is to galvanize the TBI community to gain consensus for a set of rigorous and reproducible methods, and to increase analytical transparency and data sharing to address the reproducibility crisis in the field.
Adult-acquired buried penis (AABP) is a condition associated with penile entrapment, penile shaft skin loss, and an enlarged pannus which engulfs the penis. The increased prevalence, awareness, and availability of surgical repair have led to a relative standardization in repairs. The surgical approach to AABP has evolved from a lengthy procedure with extended inpatient stay to one that may be done in an outpatient setting. The critical steps for surgical management of AABP have remained largely consistent over time, including: release of the penis with removal of diseased skin, suprapubic and/or abdominal panniculectomy, and skin coverage (usually with grafts). In contrast, the finer points of the procedure and perioperative care have undergone evolution. The aim of our approach was to optimize postoperative aesthetic and functional outcomes. Our perioperative management was modeled after enhanced recovery after surgery principles to minimize morbidity and expedite recovery. There remains room for improvement in the care of individuals with AABP, specifically multi-institutional collaboration, development of disease-specific outcome measures, and standardization of treatment algorithms.
Background: Thumb basilar joint arthritis is a common pathology treated by hand surgeons. Trapeziectomy followed by various reconstructive techniques have been described; however, treatment options after failed primary trapeziectomy and ligament reconstruction (LRTI) with painful subsidence are not well studied. Suture button suspensionplasty has emerged as a new primary reconstructive procedure in recent years. We aim to report our experience of using suture button suspensionplasty as a salvage procedure for patients presenting with recurrent painful subsidence after primary surgical intervention. Methods: A retrospective chart review of all patients undergoing suture button suspensionplasty between 2016-2017 was performed. Patients who had the procedure after failed primary trapeziectomy and LRTI were included in the study. Patient demographic data, diagnostic imaging, clinical presentation, operative details, surgical pathology, and clinical outcomes were reviewed. Results: Thirty-two button suspensionplasties were performed in the 2-year span. Five patients underwent surgery for failure of previous trapeziectomy with ligament reconstruction. All patients had Eaton stage III arthritis at original presentation. The average age was 59 yr. Average follow-up was 13 mo (11-18 mo). All patients reported significant improvement in pain and hand function after revision surgery. One patient had a second revision surgery because of failure of the first revision secondary to a fall. Postoperative Disabilities of Arm Shoulder and Hand (DASH) score range from 13.3 to 25, with an average of 19.8. Conclusions: Suture button suspensionplasty is a viable option for patients who present with painful subsidence after failure of primary surgical intervention for basilar joint arthritis.
Computed tomography (CT) analysis can facilitate abdominal flap harvest when there is aberrant anatomy in the deep inferior epigastric (DIE) system. Many patients undergoing breast reconstruction have some history of abdominal or pelvic surgery, including Caesarean section, liposuction, anterior approaches for spine surgery, or open appendectomy. The resulting vascular stenosis or occlusion can be identified on preoperative imaging and reconstructed with vein grafting if perforator anatomy to the DIE system is preserved, thus avoiding extra-abdominal flap harvest in the large-breasted bilateral reconstruction patient with an otherwise formidable bank of abdominal tissue (Fig. 1).1 (See figure, Supplemental Digital Content 1, which shows the Axial CT section of right DIEA with the presence of contrast within cranial pedicle. https://links.lww.com/PRSGO/B880.) (See figure, Supplemental Digital Content 2, which shows the axial CT section of right DIEA with void of contrast in pedicle at this level. https://links.lww.com/PRSGO/B881.) (See figure, Supplemental Digital Content 3, which shows the axial CT section of right DIEA with the presence of contrast within caudal pedicle. https://links.lww.com/PRSGO/B882.)Fig. 1.: CT showing DIEA flow void, the so-called DIEA interruptus. A, Large, peri-umibilical perforators are noted on CT angiography. B, Anteroposterior view showing stenosis in the right inferior epigastric artery. This patient went on to have successful bilateral autologous breast reconstruction from the abdomen with 1000 gram flaps using vein grafts from the dorsum of the foot to replace the stenotic segment of the DIE artery.Although extra-abdominal donor sites do exist, thigh scar placement, stacked breast reconstruction, and/or intraoperative repositioning may be necessary to replace mastectomy volumes when abdominal tissues cannot be harvested. Arguably, these advanced reconstructive options require greater time and morbidity when compared with a vein graft harvest and anastomosis. In consideration of this reality, but also for the purposes of perforator selection and surgical planning, experienced breast reconstruction surgeons routinely order preoperative CT angiography.1 Vein grafts have been used as a salvage option when intraoperative difficulties are encountered, such as for intraflap anastomosis to augment arterial perfusion or venous drainage in cases of superficial dominant flap circulations or bipedicle flaps, perforator injury or inadequacy, vessel injury, and short pedicles at the time of inset. Technically, it is important to reverse valved donor veins before anastomosis to avoid flow against valved systems. When additional donor sites are not preferred, harvest from redundant banks of vein within the operative field may be advisable. Contralateral unused DIE or superficial inferior epigastric vessels (artery or vein) within the abdominal field or the lateral thoracic or thoracodorsal branches within the mastectomy pocket can be used.2,3 Longer vein grafts can be harvested from the extremities such as the dorsum of the foot or the saphenous systems.4 (See figure, Supplemental Digital Content 4, which shows the pedal vein and lesser saphenous vein graft harvest. https://links.lww.com/PRSGO/B883.) Before planning for vein graft harvest, collateral pedicles (such as the deep circumflex iliac, superficial inferior epigastric, superficial circumflex iliac, and intercostal vessels) should be interrogated. In the case of a long-standing stenotic pedicle, collateral vasculature may become dominant in the flap. Intraoperative perfusion assessment can be performed by applying a temporary vascular clamp before dividing vessels. Depending on flap lie, it may also be more practical to select alternative recipient vessels, such as the cephalic vein turn-down or the thoracodorsal system, than to proceed with longer vein grafts.5 These options should be considered before committing to vessel harvest outside the surgical site. In summary, for cases where pedicle discontinuity exists, a vein graft can be planned to add the pedicle length necessary to permit abdominal flap harvest as long as the dominant perforators are in line with a healthy segment of pedicle. To clarify, this article does not advocate taking patients to surgery for DIEP flap categorically when aberrancies in the deep inferior epigastric system exist, but an appropriate discussion and planning can be undertaken with the patient, in particular when large volume transfers or bilateral reconstructions are planned.
Abstract The brain’s biological age (BA) reflects structural changes related to neuroanatomic senescence. BA is estimated from magnetic resonance images (MRIs) using convolutional neural networks (CNNs), which provide interpretability through saliency maps. By conveying the importance of brain regions to BA estimation, these maps reveal sex differences in brain-aging. We compared two CNN architectures to assess the reproducibility of such differences. Both regression CNNs had T1-weighted MRIs as inputs; outputs were estimated BAs. One CNN was trained on males and females separately, whereas the other was trained on both sexes. The dataset used consisted of T1-weighted MRIs from 5,851 cognitively normal individuals (3,142 females) aged 22 to 95 years, sampled from the Alzheimer’s Disease Neuroimaging Initiative (N = 510), Human Connectome Project Aging (N = 508) and Young Adult (N = 1,112), and UK Biobank (N = 3,721). For both models, compared to the average saliency for a null distribution, males’ BA estimation relied significantly (p < 0.05) more on the right lateral temporal lobe and superior frontal gyrus. Females’ BA estimation depended significantly (p <; 0.05) more on the right posterior and bilateral occipital regions, and medial parietal lobe. Simulated alterations in brain morphometry indicated saliencies correctly revealed regions with aging-related dynamics, which confirm prior findings on sex differences in brain-aging. Variations in CNN models’ saliencies did not affect overall anatomic patterns, suggesting that CNNs can capture brain-aging patterns robustly despite architecture differences. Novel statistical models for formal comparison of CNN saliencies should be developed to accommodate their nonlinear nature.
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