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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.

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.

Extracranial carotid and vertebral artery dissection is an important cause of stroke, especially in young people. In some observational studies it has been associated with a high risk of recurrent stroke. Both antiplatelet drugs and anticoagulant drugs are used to reduce risk of stroke but whether one treatment strategy is more effective than the other is unknown. We compared their efficacy in the Cervical Artery Dissection in Stroke Study (CADISS), with the additional aim of establishing the true risk of recurrent stroke. We did this randomised trial at hospitals with specialised stroke or neurology services (39 in the UK and seven in Australia). We included patients with extracranial carotid and vertebral dissection with onset of symptoms within the past 7 days. Patients were randomly assigned (1:1) by an automated telephone randomisation service to receive antiplatelet drugs or anticoagulant drugs (specific treatment decided by the local clinician) for 3 months. Patients and clinicians were not masked to allocation, but investigators assessing endpoints were. The primary endpoint was ipsilateral stroke or death in the intention-to-treat population. The trial was registered with EUDract (2006-002827-18) and ISRN (CTN44555237). We enrolled 250 participants (118 carotid, 132 vertebral). Mean time to randomisation was 3·65 days (SD 1·91). The major presenting symptoms were stroke or transient ischaemic attack (n=224) and local symptoms (headache, neck pain, or Horner's syndrome; n=26). 126 participants were assigned to antiplatelet treatment versus 124 to anticoagulant treatment. Overall, four (2%) of 250 patients had stroke recurrence (all ipsilateral). Stroke or death occurred in three (2%) of 126 patients versus one (1%) of 124 (odds ratio [OR] 0·335, 95% CI 0·006–4·233; p=0·63). There were no deaths, but one major bleeding (subarachnoid haemorrhage) in the anticoagulant group. Central review of imaging failed to confirm dissection in 52 patients. Preplanned per-protocol analysis excluding these patients showed stroke or death in three (3%) of 101 patients in the antiplatelet group versus one (1%) of 96 patients in the anticoagulant group (OR 0·346, 95% CI 0·006–4·390; p=0·66). We found no difference in efficacy of antiplatelet and anticoagulant drugs at preventing stroke and death in patients with symptomatic carotid and vertebral artery dissection but stroke was rare in both groups, and much rarer than reported in some observational studies. Diagnosis of dissection was not confirmed after review in many cases, suggesting that radiographic criteria are not always correctly applied in routine clinical practice. Stroke Association.

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

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.

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.