Bovine-derived dural substitutes are commonly used in cranial and spinal duraplasty. Although they are generally well tolerated, allergic reactions have been reported—almost all presented with eosinophilic meningitis. A 7-year-old girl with Li-Fraumeni syndrome and diffuse pediatric glioma underwent a third salvage resection in which a bovine collagen dural onlay was placed. Ten days post operatively, she developed fever, lethargy, and a subcutaneous scalp fluid collection. Cultures and imaging were negative for infection; cerebrospinal fluid (CSF) revealed pleocytosis (elevated white blood cells and protein) without eosinophilia. High-dose dexamethasone produced transient clinical and radiographic improvement, but fever and fluid re accumulated whenever steroids were tapered. Given the steroid dependence and persistently negative infectious work-up, the graft was explanted. Pathology demonstrated a foreign-body giant cell reaction without eosinophils, and the patient’s symptoms resolved permanently after removal. This report documents the first pediatric case of bovinederived dural graft hypersensitivity without eosinophilic meningitis. Clinicians should consider graft-related allergy in children who develop recurrent fluid collections and fevers after duraplasty—even when CSF eosinophils are absent and cultures remain negative and should recognize that definitive treatment may require graft removal rather than prolonged steroid therapy.

Objective: Bariatric surgery effectively treats non-alcoholic fatty liver disease (NAFLD). The glutamate-serine-glycine (GSG) index has emerged as a non-invasive diagnostic marker for NAFLD, but its ability to monitor treatment response remains unclear. This study investigates the GSG index's ability to monitor NAFLD's response to bariatric surgery. Methodology: Ten NAFLD participants were studied at baseline and 6 months post-bariatric surgery. Blood samples were collected for serum biomarkers and metabolomic profiling. Hepatic steatosis [proton density fat fraction (PDFF)] and fibroinflammation (cT1) were quantified with multiparametric magnetic resonance imaging (mpMRI), and hepatic stiffness with magnetic resonance elastography (MRE). Amino acids and acylcarnitines were measured with mass spectrometry. Statistical analyses included paired Student’s t-test, Wilcoxon-signed rank test, and Pearson’s correlation. Results: Eight participants provided complete data. At baseline, all had hepatic steatosis (BMI 39.3 ± 5.6 kg/m2, PDFF ≥ 5%). Post-surgery reductions in PDFF (from 12.4 ± 6.7% to 6.2 ± 2.8%, p = 0.013) and cT1 (from 823.3 ± 85.4ms to 757.5 ± 41.6ms, p = 0.039) were significant, along with the GSG index (from 0.272 ± 0.03 to 0.157 ± 0.05, p = 0.001). Conclusion The GSG index can potentially be developed as a marker for monitoring the response of patients with NAFLD to bariatric surgery.
Non-alcoholic Fatty Liver Disease ; Amino Acids ; Metabolomics

Background: and Purpose Infarct volume and other imaging markers are increasingly used as surrogate measures for clinical outcome in acute ischemic stroke research, but how improvements in these imaging surrogates translate into better clinical outcomes is currently unclear. We investigated how changes in infarct volume at 24 hours alter the probability of achieving good clinical outcome (modified Rankin Scale [mRS] 0–2). Methods: Data are from endovascular thrombectomy patients from the randomized controlled ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke) trial. Infarct volume at 24 hours was manually segmented on non-contrast computed tomography or diffusion-weighted magnetic resonance imaging. Probabilities of achieving good outcome based on infarct volume were obtained from a multivariable logistic regression model. The probability of good outcome was plotted against infarct volume using linear spline regression. Results: A total of 1,099 patients were included in the analysis (median final infarct volume 24.9 mL [interquartile range: 6.6–92.2]). The relationship between total infarct volume and good outcome probability was nearly linear for infarct volumes between 0 mL and 250 mL. In this range, a 10% increase in the probability of achieving mRS 0–2 required a decrease in infarct volume of approximately 34.0 mL (95% confidence interval: -32.5 to -35.6). At infarct volumes above 250 mL, the probability of achieving mRS 0–2 probability was near zero. The relationships of tissue-specific infarct volumes and parenchymal hemorrhage volume generally showed similar patterns, although variability was high. Conclusion There seems to be a near-linear association between total infarct volume and probability of achieving good outcome for infarcts up to 250 mL, whereas patients with infarct volumes greater than 250 mL are highly unlikely to have a favorable outcome.

Humans ; Carcinoma, Hepatocellular/epidemiology* ; Liver Neoplasms/epidemiology* ; Prothrombin ; Biomarkers

Antiphospholipid syndrome (APS) is a thromboinflammatory disease with a variety of clinical phenotypes. Primary thrombosis prophylaxis should take an individualized risk stratification approach. Moderate-intensity vitamin K antagonist such as warfarin remains the primary strategy for secondary thrombosis prophylaxis among APS patients, especially for patients with predominantly venous disease. For now, direct oral anti-coagulants should be avoided in most APS patients, especially those with history of arterial manifestations. Obstetric APS management should be tailored based on an individual patient's antiphospholipid antibody profile, and obstetric and thrombotic history. Pharmacological agents beyond anticoagulants may be considered for the management of microthrombotic and nonthrombotic manifestations of APS, although more data are needed. A relatively recent discovery in the area of APS pathogenesis is the implication of neutrophil extracellular traps in thrombin generation and initiation of inflammatory cascades. APS is a complex thromboinflammatory disease with a broad clinical spectrum. Personalized therapy according to an individual's unique thrombosis and obstetric risk should be advocated.

In this paper, we aim to provide professional guidance to clinicians who are managing patients with chronic liver disease during the current coronavirus disease 2019 (COVID-19) pandemic in Singapore. We reviewed and summarised the available relevant published data on liver disease in COVID-19 and the advisory statements that were issued by major professional bodies, such as the American Association for the Study of Liver Diseases and European Association for the Study of the Liver, contextualising the recommendations to our local situation.
COVID-19/epidemiology* ; Carcinoma, Hepatocellular/therapy* ; Chronic Disease ; Hepatitis B, Chronic/therapy* ; Hepatitis C, Chronic/therapy* ; Humans ; Liver Cirrhosis/therapy* ; Liver Diseases/therapy* ; Liver Neoplasms/therapy* ; Liver Transplantation ; Singapore/epidemiology*

The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap that has been used successfully in the reconstruction of defects across the body. In specific cases, it may prove superior to more commonly used options (e.g., anterolateral thigh flap and radial forearm free flap). Historically, a disadvantage of the MSAP flap is the relatively small surface area it provides for reconstruction. We recently encountered a patient with extensive pelvic injuries from prior trauma resulting in significant scarring and contracture of the groin, tethering of the penis, and loss of the scrotum and one testicle. The patient was unable to achieve erection from tethering and his remaining testicle had been buried in the thigh. In considering the reconstructive options, he was not a suitable candidate for a thigh-based or forearmbased flap. An extended MSAP flap measuring 25 cm×10 cm was used for resurfacing of the groin and pelvis as well as for the formation of a neoscrotum. This report is the first to document an MSAP flap utilized for simultaneous groin resurfacing and scrotoplasty. Additionally, the dimensions of this flap make it the largest recorded MSAP flap to date.

BACKGROUND: Determining risk factors for diabetes insipidus (DI) after pituitary surgery is important in improving patient care. Our objective is to determine the factors associated with DI after pituitary surgery. METHODS: We reviewed records of patients who underwent pituitary surgery from 2011 to 2015 at Philippine General Hospital. Patients with preoperative DI were excluded. Multiple logistic regression analysis was performed and a predictive model was generated. The discrimination abilities of the predictive model and individual variables were assessed using the receiving operator characteristic curve. RESULTS: A total of 230 patients were included. The rate of postoperative DI was 27.8%. Percent change in serum Na (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.15 to 1.69); preoperative serum Na (OR, 1.19; 95% CI, 1.02 to 1.40); and performance of craniotomy (OR, 5.48; 95% CI, 1.60 to 18.80) remained significantly associated with an increased incidence of postoperative DI, while percent change in urine specific gravity (USG) (OR, 0.53; 95% CI, 0.33 to 0.87) and meningioma on histopathology (OR, 0.05; 95% CI, 0.04 to 0.70) were significantly associated with a decreased incidence. The predictive model generated has good diagnostic accuracy in predicting postoperative DI with an area under curve of 0.83. CONCLUSION: Greater percent change in serum Na, preoperative serum Na, and performance of craniotomy significantly increased the likelihood of postoperative DI while percent change in USG and meningioma on histopathology were significantly associated with a decreased incidence. The predictive model can be used to generate a scoring system in estimating the risk of postoperative DI.
Area Under Curve ; Craniotomy ; Diabetes Insipidus* ; Discrimination (Psychology) ; Hospitals, General ; Humans ; Incidence ; Logistic Models ; Meningioma ; Neuroendocrinology ; Neurosurgery ; Patient Care ; Postoperative Complications ; Risk Factors ; Specific Gravity ; Vasopressins

Introduction: This study investigated the association of selected biopsychosocial factors (i.e., CD4 cell count, self-stigma, and social stigma) with the quality of life and adherence to treatment of people living with HIV in the National Capital Region. Methods: A cross-sectional study design was conducted to document the health status and behavior of respondents affiliated with a clinic in Quezon City. Participants answered an online questionnaire containing the Berger HIV Stigma Scale, WHO-QOL for HIV, and HIV Treatment Adherence SelfEfficacy Scale. Bivariate analyses and prevalence risk ratios were used to determine the association of selected biopsychosocial factors with quality of life and adherence to treatment. Results: One hundred respondents were analyzed, of which 42% had CD4 cell counts < 350 cells/mm3, 43% had high self-stigma and 36% had high social stigma while 11% had poor QOL and 7% had poor ATT. There was no significant association of CD4 cell count, self-stigma and social stigma with quality of life and with adherence to treatment. Conclusion A weak association was noted between poor QOL and low CD4 cell counts and among those who felt higher social stigma, but the relationships were not significant. The association between poor ATT and the selected biopsychosocial factors was not significant.
CD4 Lymphocyte Count ; Social Stigma ; Quality of Life