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\"As globalization spreads and as we destroy the ancient ecosystems, we encounter strange and dangerous infections that originate in animals but that can be transmitted to humans. Diseases that were contained are being set free and the results are potentially catastrophic. In a journey that takes him from southern China to the Congo, from Bangladesh to Australia, David Ouammen tracks these infections to their source and asks what we can do to prevent some new pandemic spreading across the face of the earth\"--back cover.

BackgroundWallenberg syndrome was given a detailed description in 1895 by Adolf Wallenberg, who identified this condition as infarction of the lateral medulla oblongata.1 Large artery atherothrombotic causes represent 75% of cases, with cardioembolic and vertebral artery dissection being other common causes.2 3 Clinical Presentation55M with hypertension, Type 2 DM and hypercholesterolaemia presented as a code stroke to the ED after waking up at 3 am to use the bathroom and developing vertigo. He also experienced left eye conjunctival pallor. He had an ataxic gait. He had normal imaging at code stroke which did not show any acute bleed, nil large vessel occlusion and nil perfusion abnormalities. At this point, patient’s only concerning feature was ataxia and lethargy with a mild headache.He had a positive head impulse test. He was discharged after clearance from physiotherapy with antiemetics and low dose prednisolone.Two days later, patient represented with worsening left sided gait unsteadiness. He had developed worsening left sided facial numbness. He also described right arm reduced sensation to hot water.MRI Brain then revealed acute ischaemia related diffusion restriction in the lateral part of medulla oblongata, measuring 9mm x 6mm x 8mm. Nil evidence of arterial dissection.ConclusionWallenbergs syndrome has myriad presentations. Despite lacking definite clinical signs consistent with central vertigo, the aforementioned patient had a large lateral medullary infarction and it was discovered only on repeat presentation, confirmed only on MRI, an imaging investigation not rapidly available as an inpatient.ReferencesLui F, Tadi P, Anilkumar AC. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 25, 2023. Wallenberg Syndrome.Inamasu J, Nakae S, Kato Y, Hirose Y. Clinical characteristics of cerebellar infarction due to arterial dissection. Asian J Neurosurg. 2018 Oct-Dec;13(4):995–1000.Saleem F, Das JM. StatPearls StatPearls Publishing; Treasure Island (FL): Aug 7, 2023. Lateral Medullary Syndrome.

PurposeTo evaluate the outcomes of a 9-mm deep anterior lamellar keratoplasty (DALK) use of Moria pre-calibrated trephine to optimize pneumatic dissection.DesignProspective, noncomparative, interventional case series. Par2cipants: A total of 1118 consecutive eyes with stromal disease, with at least 1 postoperative examination 1 month after complete suture removal.MethodsStandardized DALK was performed by fellows and senior surgeons: (1) deep trephination of the recipient bed 450 to 550 mm in depth and 9 mm in diameter; (2) pneumatic dissection; (3) debulking of approximately 80% of the anterior stroma; (4) removal of the deep stroma (bubble roof) from a central 6-mm optical zone; and (5) transplanta5on of a 9-mm anterior corneal lamella cut by microkeratome-assisted dissection (400-mm head) and sutured with a double running 10–0 nylon suture. Success rate, best spectacle-corrected visual acuity (BSCVA) and refractive astigmatism (RA) were evaluated.ResultsLarge diameter DALK was successfully performed in 1079 of 1118 eyes (97%). Pneumatic dissection was successful in 396 of 489 eyes (81%) with keratoconus without scarring, in 164 of 315 eyes (52%) with keratoconus with scarring, in 69 of 87 eyes (79%) with other DALK indications not associated with stromal scarring and in 190 of 276 eyes (69%) with other DALK indications associated with stromal scarring. Mean logMAR BSCVA was 0.10± 0.16. Mean RA was 2.7± 1.4 D. RA was greater than 4.5 D but less than 6 D in 51 eyes (5%) while RA was greater than 6 D in 15 eyes (1%). The 5- and 10-year cumulative probability for stromal rejection was 2% at 5 years and 3% and for graft survival was 99% and 98%, respectively.ConclusionThe use of Moria pre-calibrated trephine optimizes pneumatic dissection during large diameter DALK, which provides visual outcomes superior to those reported for PK with excellent 10-year survival regardless of surgical indication

Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines—based on available evidence from mostly observational studies—suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection. We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0–3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460. Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI −4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group. Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection. Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.

Palmaris longus (PL) muscle is a superficial flexor of the forearm with restricted functions (its harvest or absence does not result in any functional disorder) but great clinical importance. The flattened tendon, measuring 10 cm in length and 0.6 cm in width, presented a cleft about 3.5 cm from the palmar aponeurosis. Authors wish to sincerely thank people who donated their body to science with the purpose of performing medical education and anatomical research.

Nita's mother hunts monsters and, after Nita dissects and packages them, sells them online, but when Nita follows her conscience to help a live monster escape, she's sold on the black market in his place.

Spontaneous cervical artery dissection (sCAD) is a serious condition that carries with it a high rate of morbidity and mortality. This review highlights the pearls and pitfalls of sCAD, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. sCAD is a condition affecting the carotid or vertebral arteries and occurs as a result of injury and compromise to the arterial wall layers. The dissection most commonly affects the extracranial vessels but may extend intracranially, resulting in subarachnoid hemorrhage. Patients typically present with symptoms due to compression of local structures, and the presentation depends on the vessel affected. The most common symptom is headache and/or neck pain. Signs and symptoms of ischemia may occur, including transient ischemic attack and stroke. There are a variety of risk factors for sCAD, including underlying connective tissue or vascular disorders, and there may be an inciting event involving minimal trauma to the head or neck. Diagnosis includes imaging, most commonly computed tomography angiography of the head and neck. Ultrasound can diagnose sCAD but should not be used to exclude the condition. Treatment includes specialist consultation (neurology and vascular specialist), consideration of thrombolysis in appropriate patients, symptomatic management, and administration of antithrombotic medications. An understanding of sCAD can assist emergency clinicians in diagnosing and managing this potentially deadly disease.