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ABSTRACTBackgroundPancreatic cysts are increasingly discovered on imaging studies performed for unrelated conditions. Currently, surveillance of these lesions poses a substantial burden on patients, and health care recourses. We hypothesized that individuals with small and stable cysts have a diminutive risk of progressing to high‐grade dysplasia (HGD) or pancreatic cancer (PC) that is similar to that in the general population.MethodsThis nested PACYFIC‐study is a collaboration among 44 centers in Europe and Northern‐America, and investigates the risk of HGD and PC for different cyst sizes and growth rates in participants without baseline worrisome features (WF) or high‐risk stigmata (HRS).ResultsOf the 2369 PACYFIC participants, 975 met the inclusion criteria, with a mean age of 67 years (SD 13) and 65% being female. Of these, 438 individuals (45%) had a baseline small cyst size (< 15 mm), and 885 (91%) individuals had a slow growth rate (< 2.5 mm/year). During a median follow‐up of 45 months (IQR 27), 20 individuals (2.1%) developed HGD, or PC. Individuals with small cysts had a 1.5‐fold lower risk of developing WF or HRS (hazard ratio [HR] 0.7 [0.5–1.0], p = 0.03) than those with larger cysts but a similar risk of developing HGD or PC (p > 0.05). Slow growth was protective against the development of WF or HRS (HR 0.4 [0.2–0.6], p < 0.001) and HGD or PC (HR 0.04 [95% CI 0.02–0.12], p < 0.001). Individuals with small, stable sized cysts without baseline WF or HRS did not have a higher risk of HGD or PC than the general population (standardized incidence ratio [SIR] 1.13 [95% CI 0.01–6.30]).ConclusionCyst size < 15 mm and growth rate < 2.5 mm/year appear to be “reassuring” features associated with a negligible risk of developing WF or HRS and HGD or PC. For cysts with these characteristics—and without baseline WF or HRS—less intensive surveillance (than currently recommended) or even cessation may be appropriate.

Flexible intramedullary nail fixation of pediatric femoral shaft fractures offers advantages such as shorter hospital stays, faster return to function, and less associated costs when compared with traction and casting. This study compared the biomechanical performance of three configurations: 2CS, 2CL, and 3CL. Thirty synthetic femur models with identical, length-unstable, spiral fractures were tested using a three-dimensional camera system to assess real-time micromotion. Three groups were analyzed: (a) 2CS – two 3.5 mm C- and S-shaped nails inserted anterograde, (b) 2CL – one ‘C’ and one ‘S’ shaped 3.5 mm titanium nail-inserted retrograde from a single lateral entry, (c) 3CL – two ‘C’ shaped 3.5 mm titanium nails inserted medially and laterally with a third ‘C’ shaped 2.5 mm nail placed retrograde from an anterolateral site. Torsional loading, cyclical loading, and load-to-failure tests were conducted. The 3CL configuration demonstrated superior biomechanical performance. It exhibited the highest torsional stiffness [0.67 ± 0.06 Nm/° for external rotation (ER), 0.404 = ± 0.06 Nm/° for internal rotation (IR); P = 0.002], least displacement (0.05 ± 0.02 vs. 0.30 ± 0.02 mm for 2CL and 0.57 ± 0.05 mm for 2CS; P = 0.012), and required the highest load-to-failure (162 ± 83 vs. 1064 ± 75 N for 2CL and 790 ± 34 N for 2CS; P = 0.016).The 3CL configuration provided superior strength and stability across all tests, supporting its role in the fixation of length-unstable pediatric femoral fractures.

Objective Motor neuron disease (MND) is a progressive neurological disorder with no known cure that damages motor neurons. The purpose of this analysis is to examine the place of death for MND patients in the United States during the coronavirus disease 2019 (COVID-19) pandemic and to investigate the extent of specific comorbidities. Methods We obtained death certificate and associated comorbidities data for all U.S. MND deaths from 2018 to 2021 and conducted a population-based cross-sectional analysis of the deaths pre-COVID-19 (2018-2019) and during COVID-19 (2020-2021). We hypothesized that place of death and comorbidities associated with place of death for MND patients in the United States were altered during the COVID-19 pandemic in comparison to the 2 years period before the pandemic. Results We analyzed 30 066 MND deaths (14 562 pre-COVID-19 and 15 504 during COVID-19) aged 20 years and older. During COVID-19, MND deaths at home increased (54.4% vs 45.5% pre-COVID). Hispanic individuals had an increased likelihood of dying at home compared to a nursing home or hospice (OR = 1.57, 95%CI: 1.22-2.02), but a decreased likelihood compared to a hospital (OR = 0.61, 95% CI: 0.51-0.72). Among the top comorbidities listed, there was a 27.8% increase in diabetes mellitus and a 20.2% increase in essential hypertension during COVID-19. During COVID-19, diabetes mellitus was more commonly reported as a comorbidity for deaths occurring in hospitals (OR = 1.40, 95%CI: 1.03-1.89) or at home (OR = 1.26, 95%CI: 1.03-1.55), while essential hypertension was more commonly reported with deaths at home (OR = 1.17, 95%CI: 1.01-1.36). Conclusion Our analysis showed an increase in at-home MND deaths as well as certain comorbidities during the COVID-19 pandemic, suggesting MND patients had a higher likelihood of death from non-COVID-19 comorbidities.

Cerebrospinal fluid venous fistulas (CSFVF) can lead to spontaneous intracranial hypotension, causing debilitating symptoms in patients. The transvenous embolization technique has been developed to occlude leakage sites via an endovascular approach. However, the spinal venous anatomy remains relatively unfamiliar to many neurointerventionalists. This technical video presents a swine model designed to train physicians in navigating the spinal venous system, performing embolization injections, observing their spread, and testing new embolization systems for treating CSFVF. Although there are slight anatomical differences, the spinal venous system in swine closely resembles that of humans, including its navigability and employing liquid embolic agents. We successfully embolized multilevel spinal vasculature that can potentially drain into a fistula formation, without any complications.

Background The effectiveness of endovascular thrombectomy (EVT) for low Alberta Stroke Program Early CT score (ASPECTS) stroke patients with occlusion of the second segment of the middle cerebral artery (M2) is unclear. Methods This was a multicenter retrospective study. Patients with M1 or M2 occlusions and low ASPECTS (<6) who underwent successful EVT (modified treatment in cerebral ischemia score of 2b or higher) were included. Primary outcome was futile EVT reperfusion (defined as 90-day modified Rankin scale of 5 or 6). Other outcomes of interest include acceptable outcomes (modified Rankin scale of 3 or less) and intracranial hemorrhage (ICH), and all-cause 90-day mortality. Outcomes for M1 patients were compared to M2 patients with multivariable logistic regression models accounting for potential confounders. Results 173 patients with M1 or M2 occlusions and low ASPECTS (<6) who underwent successful EVT were identified. After multivariable adjustments, M2 patients had significantly higher odds of futile reperfusion (OR 5.48 [95%CI 1.91 to 15.7], p = 0.002), lower odds of acceptable outcomes (OR 0.33 [95%CI 0.12 to 0.89], p = 0.028), and higher odds of all-cause mortality (OR 4.90 [95%CI 1.65 to 14.5], p = 0.004). These findings suggest that EVT's efficacy for low-ASPECTS stroke patients may be diminished for patients with M2 occlusions. M2 occlusion was not significantly associated with ICH. Conclusions Among low-ASEPCTS stroke patients who underwent successful EVT, those with M2 occlusions had significantly higher odds of poor outcome compared to those with M1 occlusions.

An elderly woman presented with coma secondary to acute-on-chronic liver failure and was found to have severe hyperammonaemia. MR scan of brain showed extensive bilateral and symmetric cortical and thalamic fluid-attenuated inversion recovery hyperintense signals and diffusion restriction. How should clinicians address the prognosis of such cases? Postmortem findings from this case provide new insights in pathophysiology.

Background Although micro‐ and nanoplastics are an emerging risk factor for the development of cardiovascular diseases, the association of marine microplastic levels (MMLs) with the burden of cardiometabolic diseases at a population level remains unexplored. We investigated the relationship between the mean microplastic concentration in ocean water within 200 nautical miles of the US coastline and the prevalence of type 2 diabetes, coronary artery disease, and stroke in nearby counties. Methods Microplastic concentration data within 200 nautical miles of the US coastline were geospatially analyzed to calculate mean MMLs. The coastal counties were stratified into 4 categories based on MMLs in the adjacent ocean water body: low, medium, high, or very high. The Behavioral Risk Factor Surveillance System 2019 to 2020 survey data were used to identify the prevalence of type 2 diabetes, coronary artery disease, and stroke in these counties. Univariate and population‐weighted multivariate quasi‐Poisson regression, adjusted for county‐level confounding variables, was used to evaluate the unadjusted and adjusted associations between disease prevalence and MMLs. Results The mean age of the population was 43±6 years. After adjusting for age, sex, physician access, and socioenvironmental vulnerabilities at the county level, counties with very high MMLs exhibited an 18%, 7%, and 9% higher adjusted prevalence of type 2 diabetes, coronary artery disease, and stroke, respectively, compared with those with low levels. Conclusion Marine microplastic levels were significantly associated with the prevalence of cardiometabolic diseases in coastal counties. Comprehensive studies at an individual level are needed to further investigate the health impacts of microplastic pollution.

Objective: We comparatively analyzed the longitudinal outcomes of conversion to open procedure, laparoscopic subtotal cholecystectomy (CCY), and laparoscopic cholecystostomy tube placement. Background: Severe cholecystitis often causes dense inflammation that distorts the hepatocystic anatomy and can make safe dissection during CCY challenging. However, controversy exists regarding the optimal bailout procedure in such situations. Methods: The New York and Florida State all-claims databases were queried for patients who underwent laparoscopic CCY for acute cholecystitis from 2012 to 2021. Hierarchical logistic regression models were used to obtain adjusted estimates, with fixed effects assigned to patient-level variables and random effects assigned to hospital identifiers to adjust for intraclass correlation. Results: Of 384,948 laparoscopic CCYs performed, 5448 (1.4%) were not completed laparoscopically; 1370 underwent conversion to open procedure, 2646 underwent laparoscopic subtotal CCY, and 1432 underwent laparoscopic cholecystostomy tube placement. The conversion to open rate decreased from 0.6% in 2012 to 0.3% in 2021, while the laparoscopic subtotal CCY rate increased from 0.2% in 2012 to 1.4% in 2021. The 1-year bile duct injury (BDI) rate was highest for the conversion to open group (4.4%), followed by the laparoscopic subtotal CCY (0.8%) and laparoscopic cholecystostomy tube groups (0.3%, P<0.001). On adjusted analyses with the conversion to open group as the control, laparoscopic subtotal CCY (OR: 0.17, P<0.001) and laparoscopic cholecystostomy tube were associated with lower BDI rates (OR: 0.08, P<0.001, Figure). The 1-year postoperative endoscopic biliary intervention rate was lowest for the conversion to open group (4.2%), followed by the laparoscopic subtotal CCY (8.4%) and the laparoscopic cholecystostomy tube groups (8.8%, P<0.001). The completion CCY rates for the laparoscopic subtotal CCY and laparoscopic cholecystostomy tube groups were 2.1% and 23.4%, respectively. Among completion CCYs, the open rates were 56.4% in the laparoscopic subtotal CCY group versus 24.5% in the laparoscopic cholecystostomy tube group (P<0.001). Conclusions: In patients with severe cholecystitis requiring a bailout procedure, the BDI rate was highest after conversion to open procedure. Laparoscopic subtotal CCY and laparoscopic cholecystostomy tube were associated with lower BDI rates at the cost of higher postoperative endoscopic biliary intervention rates. Completion CCYs were required in 2.1% and 23.4% of patients who underwent laparoscopic subtotal CCY and laparoscopic cholecystostomy tube placement, respectively, of which the former group’s CCY was more likely to require an open operation.

Aims Testicular sex cord‐stromal tumours (TSCSTs) are relatively rare, accounting for ~5% of all testicular neoplasms. They were historically classified into Leydig cell tumour, Sertoli cell tumour, granulosa cell tumour, and unclassified sex cord‐stromal tumour. More recently, classification was expanded to incorporate additional histologic types, including some associated with inherited cancer predisposition syndromes. However, the classification of TSCSTs still relies entirely on morphology, with some tumour types being defined based on their resemblance to ovarian counterparts. In recent years, molecular studies have identified drivers and genomic alterations associated with aggressive behaviour and progression; however, these findings have not yet impacted classification and management. Methods and results Under sponsorship of the International Society of Urological Pathology (ISUP) and the Genitourinary Pathology Society (GUPS), a group of genitourinary pathologists was assembled in 2023 with the aim of assessing how to use these new data to improve the classification and management of TSCSTs. Conclusions This paper summarizes the recommendations derived from the consensus activities and the first meeting of the te sticular s ex cord‐ s tromal t umour (TESST) group (held at Johns Hopkins Hospital, Baltimore, USA, 3/23/2024).