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Dynorphin/Kappa-Opioid Receptor System Modulation associated with Cortical Circuitry.
5%) underwent surgery for neurogenic claudication or radiculopathy for adjacent-level stenosis or disc herniation and were classified as "neurologic." Ten patients (15.4%) had progressive degenerative disc pathology at the adjacent level and were classified as "degenerative." Ten patients (15.4%) had spondylolisthesis or instability and were classified as "instability," and three patients (4.6%) required revision surgery for adjacent-level kyphosis or scoliosis and were classified as "deformity." Fifteen patients (23.1%) had multiple diagnoses that included a combination of categories and were classified as "combined." Conclusion This is the first study to propose an etiology-based classification scheme of ASDz following lumbar spine fusion. This simple classification system may allow for the grouping and standardization of patients with similar pathologies and thus for more specific pre-operative diagnoses, personalized treatments, and improved outcome analyses.Background Sacral insufficiency fracture (SIF) can cause lumbosacral radiculoplexopathy (LSRP) and is probably under-recognized. Symptoms may include nonspecific lumbar spine or buttock pain that is exacerbated by physical activity and alleviated with rest. The frequency of LSRP secondary to SIF has not been reported. Questions/purposes We aimed to determine the frequency of LSRP associated with SIF using magnetic resonance imaging (MRI) of the lumbar spine. Methods We searched a radiology database at our institution using the keywords "sacral insufficiency fracture" and "lumbar spine MRI" for patient records from January 2014 through December 2017. We assessed for the presence of LSRP, reflected by elevated T2-weighted or short tau inversion recovery (STIR) signal intensity and enlargement of the nerve on noncontrast lumbar spine MRI. An incompletely healed vertically oriented SIF was confirmed if there was a persistent bone marrow edema pattern adjacent to the fracture site; we did not include purely transverse SIFs. The final cohort comprised 57 patients (48 female; age range, 14 to 89 years). Results Abnormalities of the extraforaminal L5 nerve root or the combined L4 and L5 nerve roots (the lumbosacral trunk) were identified in 19 (33%) of 57 patients, with a total of 23 sites (bilateral involvement in four cases). Of the 23 abnormal nerves, 19 (82.6%) had corresponding, clinically documented radicular symptoms and 16 (69.6%) had no other explanation on MRI for their radicular symptoms other than SIF. Conclusions LSRP caused by SIF is an entity all radiologists should be cognizant of, especially in cases of otherwise unexplained radicular symptoms. The diagnosis of SIF can be helpful in cases involving concomitant multilevel lumbar spondylosis and neural foraminal stenosis.Background Paravalvular leak (PVL) is common after transcatheter aortic valve implantation (TAVI) and has been linked with worse survival. This study aimed to investigate the determinants and outcome of PVL after TAVI and determine the role of aortic valve calcification (AVC) distribution in predicting PVL. Methods and results This was a retrospective cohort study of 270 consecutive patients who underwent TAVI. Determinants and outcomes of ≥mild PVL were assessed. Matching rates of PVL jet with AVC distribution were calculated. AVC volume, larger annulus dimensions, and transvalvular peak velocity were risk factors for ≥mild PVL after TAVI. AVC volume was an independent predictor of ≥mild PVL. On the other hand, annulus ellipticity, left ventricular outflow tract nontubularity, and diameter-derived prosthesis mismatch were not found to predict PVL after TAVI. PVL jet matched, in varying proportions, with calcification at all aortic root regions, and the highest matching rate was with calcifications at body of leaflets. Moreover, matching rates were less with commissure compared to cusp calcifications. Mild or greater PVL was not associated with all-cause and cardiovascular mortality up to 1-year follow-up. Conclusion ≥mild PVL after TAVI is common and can be predicted by aortic root calcification volume, larger annulus dimensions, and pre-TAVI transvalvular peak velocity, with calcification volume being an independent predictor for PVL. However, annulus ellipticity, left ventricular outflow tract nontubularity, and diameter-derived prosthesis mismatch had no role in predicting PVL. Importantly, body of leaflet calcifications (versus annulus and tip of leaflet) and cusp calcifications (versus commissure calcification) are more important in predicting PVL. No association between ≥mild PVL and increased risk of all-cause and cardiovascular mortality at 1-year follow-up.Obesity is a chronic disease that has increased in prevalence in the United States and is a risk factor for the development of nephrolithiasis. As with other medical conditions, obesity should be considered when optimizing surgical management and choosing kidney stone procedures for patients. In this review, we outline the various procedures available for treating stone disease and discuss any discrepancies in outcomes or complications for the obese cohort.The prevalence of obesity is rising and places this cohort at risk for developing kidney stones. Some of the pathophysiologic responses that link obesity and kidney stone formation have been identified. Herein, we review the involved mechanisms driving this relationship and the impact of various weight loss strategies on kidney stone risk.Active surveillance (AS) is a safe and reasonable management strategy for many patients with small renal masses (SRM) suspicious for a clinical T1a renal cell carcinoma based on excellent metastasis-free and cancer-specific survival. However, the expansion of robotic extirpation of SRM has outpaced the adoption of AS, resulting in the possibility of overtreatment for select patients with SRM, especially the elderly and comorbid. In this review of AS for SRM, with a focus on the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) Registry, we detail the rationale behind AS, review lessons learned from the past decades of literature, and offer suggestions for appropriate patient selection and follow-up. An improved understanding of the data supporting AS will empower physicians and patients to more comfortably pursue AS to avoid over-treatment and provide individualized care to patients with SRM.Upper tract urothelial cancers (UTUC) are frequently managed by radical nephroureterectomy (RNU), a major operative procedure that may entail short-term morbidity and long-term decline in renal function. Kidney-sparing procedures offer a less invasive alternative to RNU for low-risk, low-grade UTUC (LG-UTUC). They are associated with similar disease-specific survival rates and better long-term renal function, albeit with a potentially increased risk of recurrence. Strategies to decrease LG-UTUC recurrence include improved risk stratification and enhanced endoscopic instrumentation. Chemoablation may represent an alternative, innovative kidney-sparing approach for LG-UTUC.Arterial hypertension is the main identifiable cardiovascular risk factor, and although the benefit of blood pressure reduction is universally acknowledged, the scientific community has long been divided over the therapeutic blood pressure targets to be reached, also considering the estimated overall cardiovascular risk and the presence of individual risk factors and associated comorbidities. During the last few years, numerous clinical studies and meta-analyses, in particular, the SPRINT study, have been published, demonstrating the advantages of an intensive antihypertensive treatment, over a target blood pressure value ( less then 140/90 mmHg), in the reduction of major cardiovascular events, myocardial infarction, stroke, heart failure, and all-causes cardiovascular mortality. Stemming from these results the major International Guidelines revisited the therapeutic objectives, recommending blood pressure value less then 130/80 mmHg for the vast majority of hypertensive patients until the age of 65 and sugof Hypertension (ESC/ESH) 2018 Guidelines, specifically the use of renin-angiotensin-aldosterone system inhibitors [angiotensin-converting enzyme (ACE) inhibitors and Sartans], in combination with calcium antagonist and/or thiazide diuretics, with the option to add antagonist of mineralcorticoid receptors, when an adequate blood pressure control has not been reached, or other classes of drugs, such as beta-blockers, when specific clinical indications are present, first and foremost ischaemic cardiomyopathy or heart failure. The newly proposed therapeutic goals are particularly important in high-risk patients, such as patients with previous cardiovascular events, diabetes mellitus, renal insufficiency, and patients older than 65 years of age.Beginning in December 2008, under the auspices of Food and Drug Administration, numerous controlled clinical trial were planned, and in part completed, concerning the cardiovascular (CV) effects of hypoglycaemic drug in patients with Type 2 diabetes mellitus. At least 9 studies have been concluded, 13 are still open, and 4 have been initiated and closed ahead of time. Of the nine completed studies, three concerned inhibitor of the dipeptidyl peptidase 4 (inhibitors of DPP-4), four the glucagon-like peptide 1 agonist (GLP-1 agonist), and two the inhibitor of sodium-glucose co-transporter-2 (inhibitors of SGLT-2). Only four studies demonstrated the superiority, and not the mere 'non-inferiority', of the anti-diabetic drugs compared to placebo, in addition to standard treatment, in terms of reduction of the primary endpoint (CV death, non-fatal myocardial infarction, and non-fatal stroke). Two of the four studies regarded GLP-1 analogues (liraglutide and semaglutide), and two inhibitors of SGLT-2 (empaglifozin and canaglifozin). As a whole, these studies provided solid data supporting major beneficial CV effects of anti-diabetic drugs. During the next 3-4 years, an equal number of studies will be completed and published, so we will soon have the 'final word' on this issue. In the meantime, the clinical cardiologist should become familiar with these drugs, selecting the patients able to gain the best clinical advantage from this treatment, also by establishing a close relationship with the diabetologist.Arterial recanalization procedures after ischaemic stroke, are now well-established treatments, within 5 h for systemic thrombolysis, and 6 h for the endovascular treatment. Ischaemic stroke with uncertain time of symptoms onset, account for 14-27% of the cases, the vast majority of which occur just after waking up, thus it is impossible to derive an exact timeline. Accordingly, these patients are frequently not eligible for acute treatment. The results of three recent trials, DAWN, DEFUSE 3, and WAKE-UP, provided the basis for a revolution in the selection of patients eligible for late revascularization, and revealed an increase in the rate of functional independence for these patients at 90 days (mRS 0-2). Advanced neuroimaging techniques have been shown to be of utmost importance in the definition of the cerebral tissue window. A wider application of these imaging techniques and standardization of the parameters of images acquisition would provide for a significant advancement in the management of ischaemic stroke in the emergency setting.
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