Cerebral Venous Sinus Thrombosis (CVST): Long-Term Single-Center Experience

CVST is a rare location of thrombosis involving Dural/ cerebral venous sinuses. It affects around 5-10 people per million population annually. It is an uncommon but life-threatening form of stroke affecting younger individuals. Therefore, identifying and treating in a timely manner is critical. Rarer thrombotic disorders like paroxysmal nocturnal hemoglobinuria (PNH) or Janus Kinase 2 (JAK2) mutation positive myeloproliferative neoplasms (MPN) can rarely present with CVST. It can also present during pregnancy for the first time. Diagnosis is often established by Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). Infections, certain medication use (asparaginase or birth control pills) could lead to CVST. Patients often present with headaches, seizures or neurological deficits. Management is often with systemic anticoagulation despite intraparenchymal hemorrhage. Reducing intracranial pressure by invasive approaches is sometimes needed.https://digitalcommons.unmc.edu/surp2022/1024/thumbnail.jp

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

The Helicobacter pylori Genome Project : insights into H. pylori population structure from analysis of a worldwide collection of complete genomes

Helicobacter pylori, a dominant member of the gastric microbiota, shares co-evolutionary history with humans. This has led to the development of genetically distinct H. pylori subpopulations associated with the geographic origin of the host and with differential gastric disease risk. Here, we provide insights into H. pylori population structure as a part of the Helicobacter pylori Genome Project (HpGP), a multi-disciplinary initiative aimed at elucidating H. pylori pathogenesis and identifying new therapeutic targets. We collected 1011 well-characterized clinical strains from 50 countries and generated high-quality genome sequences. We analysed core genome diversity and population structure of the HpGP dataset and 255 worldwide reference genomes to outline the ancestral contribution to Eurasian, African, and American populations. We found evidence of substantial contribution of population hpNorthAsia and subpopulation hspUral in Northern European H. pylori. The genomes of H. pylori isolated from northern and southern Indigenous Americans differed in that bacteria isolated in northern Indigenous communities were more similar to North Asian H. pylori while the southern had higher relatedness to hpEastAsia. Notably, we also found a highly clonal yet geographically dispersed North American subpopulation, which is negative for the cag pathogenicity island, and present in 7% of sequenced US genomes. We expect the HpGP dataset and the corresponding strains to become a major asset for H. pylori genomics

Occipital Bony Abnormality and Multiple Strokes in a Pediatric Patient

This study presents a case of a 15-year-old boy who had a right vertebral artery dissection with distal embolization from repeated trauma from an occipital bony spicule. The authors hypothesize that this bony spicule was contacting the left vertebral artery during head rotation, resulting in trauma to the vessel and formation of emboli which then showered distally, causing strokes in the posterior circulation of the brain. This specific phenomenon has previously been reported three times, only one of which was in pediatric literature. It is important for individuals to be aware of this rare anatomic cause of vertebral artery dissection in patients presenting with an odd constellation of symptoms related to strokes from vertebro-basilar system. Treatment options including early intervention with intravascular coil embolization are also discussed

Aneurysmal subarachnoid hemorrhage in patients taking direct oral anticoagulants: A case series and discussion of management

Direct oral anticoagulants are becoming more commonplace for the treatment of nonvalvular atrial fibrillation and deep vein thrombosis. Unfortunately, effective reversal agents are not widely available limiting options for neurosurgical intervention during active anticoagulation. We report a case series of 3 patients treated for aneurysmal subarachnoid hemorrhage while taking direct oral anticoagulants. All three underwent open surgical clipping after adequate time was allowed for drug metabolism. Decision-making must take into account timing of intervention, drug half-life, and currently available reversal agents. Keywords: Aneurysmal subarachnoid hemorrhage, Direct oral anticoagulant, Prothrombin complex concentrat

Optical Coherence Tomography Measurements of Choroidal Thickness in Healthy Eyes: Correlation With Age and Axial Length

BACKGROUND and OBJECTIVE: To evaluate subfoveal choroidal thickness (CT) in healthy eyes using spectral-domain optical coherence tomography (SD-OCT) and provide correlations between age and axial length.PATIENTS and METHODS: Enhanced depth SD-OCT imaging was performed with Cirrus (Carl Zeiss Meditec, Dublin, CA) and Spectralis (Heidelberg Engineering, Heidelberg, Germany) instruments. CT was measured from the outer limit of the retinal pigment epithelium to the inner surface of the sclera.RESULTS: the study enrolled 155 patients, with at least 20 in each decade between 22 and 89 years old. Mean axial length was 23.6 mm. Mean Heidelberg subfoveal CT was 286 mu m. the correlation between Heidelberg and Zeiss subfoveal CT measurements was strong (r = .978) and significant (P < .001). Mean subfoveal CT was 7.7 mu m thinner by Heidelberg versus Cirrus (P < .001). Multiple linear regression analysis revealed that age (P < .001), axial length (P = .001), and sex (P = .025) were significantly related to Heidelberg subfoveal CT.CONCLUSION: There is a strong negative correlation between CT and age (P < .001), with a 25-mu m decrease in CT for each decade of life. Increasing axial length demonstrated a negative correlation with CT, decreasing 24.9 mu m for each mm of axial length. Future studies of CT measurements can be performed on either instrument and must account for axial length, age, and sex to make appropriate conclusions.Carl Zeiss MeditecMacular Vision Research FoundationAcucelaGlaxoSmithKlineLowy Medical Research InstituteAdvanced Cell TechnologyUniv Miami, Miller Sch Med, Bascom Palmer Eye Inst, Dept Ophthalmol, Miami, FL 33136 USAWilliam Beaumont Hosp, Associated Retinal Consultants, Royal Oak, MI 48072 USAUniversidade Federal de São Paulo, Dept Ophthalmol, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Ophthalmol, São Paulo, BrazilWeb of Scienc

Abstract Number ‐ 173: Mechanical Thrombectomy in Combination with Intra‐Arterial Thrombolysis for Acute Ischemic Stroke

Introduction Mechanical thrombectomy (MT) is the gold standard for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although >70% of patients in the randomized clinical trials (RCTs) assessing the efficacy of MT for AIS‐LVO had successful recanalization, only up to 27% were free of disability according to the 90‐day modified Rankin scale (mRS) score. It is suggested that microcirculation disruption distal to the LVO might contribute to futile recanalization. Hence, combining intra‐arterial (IA) tissue plasminogen activator (tPA) with MT was investigated in a few studies in an attempt to reduce the burden of distal microthrombi and microcirculation disruption. We conducted this meta‐analysis to provide collective evidence in this regard. Methods We performed this meta‐analysis following the Preferred Reporting Items for Systematic Review and Meta‐Analyses statement recommendations. We aimed to include all original studies investigating the benefits of IA tPA in AIS patients undergoing MT.All screening and extraction stages were conducted by two authors, with a third author resolving any conflicts. Using R software, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). A fixed‐effect model was adopted to pool all data due to the absence of significant heterogeneity among the included studies. Heterogeneity was assessed using Q statistics and the I2test, where I2> 50% or P‐value < 0.05 were considered significant. Results Following the database search, a manual search of references, and different screening phases, we included 5 studies (2,686 patients) satisfying the predefined inclusion criteria. Successful recanalization rates were comparable between both groups. The 90‐day functional independence was reported in 4 studies (2,474 patients), with comparable rates between both groups (OR = 1.25; 95%CI = 0.92‐1.70; P‐value = 0.154). Mortality was reported in 3 studies (368 patients), with comparable rates between both groups (OR = 0.73; 95%CI = 0.44‐1.23; P‐value = 0.240). Symptomatic intracranial hemorrhage (sICH) was reported in 5 studies (2,678 patients) with no significant difference between the two groups (OR = 0.66; 95%CI = 0.34‐1.26; P‐value = 0.304). Conclusions The current evidence does not show any significant differences between MT alone versus MT plus IA tPA in terms of 90‐day functional independence, mortality, and sICH. With the limited number of studies and included patients, more studies are needed to investigate the benefits and safety of the combined MT and IA tPA