Christiana Hospital

Left ventricular (LV) dysfunction is a potential cardioembolic source of ischemic stroke, but its role in recurrent stroke risk and treatment response remains unclear. We explore whether LV injury associates with the risk of recurrent stroke and modifies the association between anticoagulation and stroke recurrence using real-world data. We performed a multicenter, retrospective study of Cardiac Abnormalities in Stroke Prevention and Recurrence cohort across 27 US sites. Patients with LV ejection fraction ≥20% were included. LV injury, defined as LV ejection fraction 20% to 40% and wall motion abnormality, was the primary exposure and treatment effect modifier. The treatment of interest was anticoagulant versus antiplatelet therapy. The composite outcome included recurrent stroke, major bleeding, or death. Outcomes were evaluated using unadjusted and inverse probability weighting adjusted Cox proportional hazards models, with treatment effect modification tested by LV injury status. Among 2685 patients enrolled, 2328 with complete data were analyzed (median age, 65 years; 49.8% female; median follow-up, 1.6 years). LV injury was present in 310 patients (13.3%). Overall, 535 events occurred: 258 recurrent ischemic strokes, 28 hemorrhagic strokes, 67 major hemorrhages, and 256 deaths. LV injury was associated with a higher unadjusted risk of the primary outcome (hazard ratio [HR], 1.51 [95% CI, 1.21-1.87]), though nonsignificant after inverse probability weighting adjustment (adjusted HR, 1.29 [95% CI, 0.97-1.70]). In the LV injury subgroup, anticoagulation versus antiplatelet therapy was associated with a lower risk of the primary outcome (adjusted HR, 0.24 [95% CI, 0.10-0.59]), relative to the non-LV injury subgroup (adjusted HR, 1.28 [95% CI, 0.83-1.95]; p[LV-interaction], 0.001). Similar interactions were seen for EF 20% to 40% (versus >40%; adjusted HR, 0.19 [95% CI, 0.04-0.86]; p[LV-interaction], 0.001) and wall motion abnormality (versus no wall motion abnormality; adjusted HR, 0.33 [95% CI, 0.15-0.73]). After cryptogenic stroke, anticoagulation in those with LV injury was associated with lower rates of recurrent stroke, major bleeding, and death. These findings warrant confirmation in a dedicated randomized controlled trial. URL: https://www.clinicaltrials.gov; Unique identifier: NCT06398366.

Mucinous cystic neoplasm of the gallbladder is a rare, though generally benign, entity typically diagnosed following cholecystectomy due to its nonspecific clinical presentation and imaging characteristics. This case report describes an unusual presentation of mucinous cystic neoplasm of the gallbladder mimicking a multiseptated gallbladder, wherein a 41-year-old female presented with biliary obstruction. Imaging studies revealed a gallbladder with features resembling a multiseptated gallbladder, a rare congenital variant. Consequently, the patient was scheduled for elective cholecystectomy. Intraoperative findings and histopathological examination of the resected gallbladder unexpectedly revealed a large mucinous tumor of the gallbladder and common bile duct. This case underscores the importance of considering neoplastic etiology in the differential diagnosis of atypical gallbladder imaging findings, especially in the presence of biliary obstruction, and highlights the critical role of histopathology in establishing a definitive diagnosis. Early identification and appropriate surgical intervention are essential for improving patient outcomes.

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by impairments in social communication, reciprocity, and adaptive behavior. Converging neurobiological evidence suggests that these clinical features arise from aberrant connectivity and dysregulated neuronal oscillations across distributed brain networks. In particular, dysfunction within the mirror neuron regions, concentrated in the inferior frontal gyrus (IFG) and inferior parietal lobule (IPL), has been implicated in deficits of imitation, empathy, and social cognition in ASD. Non-invasive neuromodulation using repetitive transcranial magnetic stimulation (rTMS) has shown modest behavioral benefits in ASD. However, most studies apply the conventional protocols targeting the dorsolateral prefrontal cortex. The effects of intermittent theta-burst stimulation (iTBS), a potent excitatory rTMS protocol targeting the mirror neuron regions, on the oscillatory dynamics in ASD remain largely unexplored. To investigate whether iTBS targeting the bilateral IFG and IPL modulates EEG-derived oscillatory activity in adolescents with ASD and to explore the relationship between oscillatory changes and social reciprocity. Six adolescents with Level I or II ASD (ages 13-18) underwent bilateral iTBS targeting the IFG and IPL using a figure-of-eight coil and standardized theta-burst parameters. Participants were randomized to receive either 18 active iTBS sessions or a waitlist-controlled crossover design (9 sham followed by 9 active sessions). Standard 21-channel EEG recordings were obtained during the first (EEG-1) and final (EEG-2) active stimulation sessions, including pre- and post-stimulation epochs. Power spectral analyses were conducted across frequency bands (delta through gamma). Behavioral outcomes were assessed using the Childhood Autism Rating Scale, Second Edition (CARS2), administered pre- and post-intervention. All participants tolerated the intervention without adverse effects. Behavioral analysis demonstrated a significant reduction in CARS2 scores following iTBS and is reported in detail in our prior clinical outcomes manuscript, consistent with improved social reciprocity (p < 0.001). EEG analysis revealed an immediate post-stimulation increase in gamma-band power during EEG-1 in five of six participants, whereas lower-frequency bands exhibited variable responses. In contrast, EEG-2 showed no consistent post-stimulation gamma enhancement. Net comparisons between EEG-1 and EEG-2 demonstrated attenuation of the initial gamma response in the same five participants. At the group level, gamma percent change did not reach statistical significance at EEG-1 (p = 0.12) or EEG-2 (p = 0.66), and exploratory comparisons between the 9-active versus 18-active arms did not reach statistical significance. While ipsi-directional changes in gamma power and CARS2 scores were observed in four participants, correlation was not identified in this pilot sample. Bilateral iTBS targeting the IFG and IPL induces a transient enhancement of gamma oscillations in adolescents with ASD that attenuates with repeated stimulation. This pattern is consistent with adaptive homeostatic plasticity (metaplasticity) within excitatory-inhibitory circuits, potentially mediated by GABAergic interneurons. These findings support the feasibility of EEG as an objective biomarker of neuromodulatory engagement in ASD and highlight the importance of network-level and oscillatory mechanisms in interpreting therapeutic responses. Larger, sham-controlled studies incorporating multimodal biomarkers are warranted to clarify clinical relevance and optimize personalized neuromodulation strategies.

Este artigo analisa o vínculo entre tecnologias digitais, novas metodologias de ensino, currículo e interatividade no contexto da Educação Inclusiva. Parte-se da hipótese de que a integração crítica e planejada de tecnologias, aliada a metodologias ativas e ao redesenho curricular, potencializa processos inclusivos, promovendo acessibilidade, autonomia e participação dos estudantes com necessidades educacionais especiais. Com abordagem qualitativa e caráter exploratório, realizou-se uma revisão bibliográfica (2010–2025), priorizando estudos empíricos, revisões sistemáticas e documentos de política educacional. Os achados indicam que: (a) a tecnologia assistiva tem demonstrado eficácia para ampliar acessos e possibilitar adaptações curriculares; (b) a efetiva integração curricular exige formação docente contínua, infraestrutura e mudança organizacional; (c) a interatividade (síncrona e assíncrona) promove engajamento, mas pode acentuar desigualdades sem políticas de equidade digital. Conclui-se que a promoção da inclusão por meio das tecnologias demanda ações articuladas entre currículo, práticas pedagógicas e investimentos em formação e recursos.

Percutaneous fixation of anterior pelvic ring injuries using a trans-symphyseal curved intramedullary implant offers a minimally invasive solution for challenging fracture patterns, particularly in patients with fragility fractures or compromised parasymphyseal bone. This technical report outlines key steps and intraoperative pearls for successful execution of the procedure, including fluoroscopic positioning, precise trajectory planning, safe passage across the pubic symphysis, and strategies to navigate the contralateral anterior osseous corridor. Techniques such as guide wire double-bending, cortical blocking wire placement, and elevator-assisted redirection are described in detail to address common challenges including narrow bony corridors and acute pelvic angulation. The described method avoids reliance on poor-quality ipsilateral bone and eliminates the need for extensive surgical exposure. Our early experience highlights the importance of attention to key anatomical landmarks, imaging guidance, and technical adaptability to ensure consistent implant passage, seating, and stability. This report serves as a guide for surgeons adopting the trans-symphyseal curved fixation approach.

Pregnancy orchestrates a rare physiological transformation across vascular, immune, and metabolic systems. When this dynamic balance is disrupted – as in hypertensive disorders of pregnancy – the consequences can be life-threatening, spanning maternal mortality, fetal growth restriction, and elevated long-term cardiovascular risk. Despite clear links to early placental dysfunction and systemic endothelial disruption, current screening remains clinically imprecise, biologically opaque, and logistically challenging. A shift is urgently needed – from detecting maternal complications late in gestation to understanding how pregnancy reshapes vascular physiology systemically and how this remodeling may go awry.Here we present Visionary AI, an artificial intelligence platform that integrates ultra-widefield retinal imaging (200°) with biologically grounded vascular modeling to predict hypertensive disorders of pregnancy early in gestation. Unlike prior approaches that rely on generic deep learning models and clinical inputs, Visionary AI constructs an interpretable, graph-based representation of the maternal retinal vasculature and applies topological and geometric analysis to identify condition-specific microvascular signatures. In a prospective multiethnic U.S. cohort of 1,267 pregnancies, Visionary AI achieved high predictive performance for preeclampsia (AUC = 0.90), early-onset (AUC = 0.93), and severe preeclampsia (AUC = 0.89), outperforming current clinical paradigms. It also generalized to predict gestational hypertension (AUC = 0.91) and chronic hypertension (AUC = 0.90).Topological and geometric analyses of the vasculature revealed distinct and interpretable remodeling patterns across subtypes of hypertensive disorders of pregnancy, offering mechanistic insight into their divergent pathophysiology.These results position the maternal retina as a minimally invasive, high-fidelity biosensor of early systemic vascular health and establish Visionary AI as a clinically actionable, biologically grounded diagnostic framework with potential for broad global scalability.