Lehigh Valley Hospital-Pocono

Previous single-center studies conducted in the United States in women with suspected preeclampsia indicated that serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio values of >38 measured on a widely available Elecsys immunoassay platform during the third trimester of pregnancy predicted the development of preeclampsia with severe features and adverse outcomes within 2 weeks of testing. This study aimed to validate the Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test for the prediction of preeclampsia with severe features in a United States population using the prospective Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification cohort that recruited women with a hypertensive disorder of pregnancy (gestational hypertension, chronic hypertension, de novo and superimposed preeclampsia) across 18 tertiary and community hospitals throughout the United States. We measured soluble fms-like tyrosine kinase 1-to-placental growth factor ratios using the Elecsys platform in archived serum samples from the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study that recruited hospitalized women with a hypertensive disorder of pregnancy between 23 0/7 and 34 6/7 weeks of gestation. The primary study outcome was prediction of preeclampsia with severe features within 2 weeks after testing. The secondary outcomes included a composite of adverse maternal and fetal/neonatal outcomes and prediction of delivery within 2 weeks. In the validation cohort of the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study (556 enrollments), the serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 67% positive predictive value (95% confidence interval, 61-73) and a 95% negative predictive value (95% confidence interval, 92-97) for the progression to preeclampsia with severe features within 2 weeks. Among women at <30 weeks of gestation (n=188), serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 78% positive predictive value (95% confidence interval, 68-86) and a 100% negative predictive value (95% confidence interval, 96-100) for the progression to preeclampsia with severe features within 2 weeks. The Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test performed better than standard-of-care clinical measures, with an area under the receiver operating characteristic curve of 0.92 (95% confidence interval, 0.89-0.90) for soluble fms-like tyrosine kinase 1-to-placental growth factor ratio vs <0.70 for standard-of-care tests, such as liver enzymes, platelet count, and serum creatinine (P<.001). Compared with women with a ratio of ≤38, those with a ratio of >38 had a higher risk of developing adverse maternal (relative risk, 4.9 [95% confidence interval, 2.6-9.9]; P<.001) and fetal/neonatal (relative risk, 3.2 [95% confidence interval, 2.6-4.0]; P<.001) outcomes and were more likely to deliver within 2 weeks (adjusted hazard ratio, 3.3 [95% confidence interval, 2.7-4.0]; P<.001). The soluble fms-like tyrosine kinase 1-to-placental growth factor ratio of >38 measured on the Elecsys platform predicted the development of preeclampsia with severe features, delivery, and adverse maternal and fetal/neonatal outcomes within 2 weeks of testing among preterm pregnant women hospitalized with a hypertensive disorder of pregnancy.

Introduction and Importance:Transdiaphragmatic intercostal hernias (TDIHs) are rare and typically posttraumatic. The coexistence of a TDIH with congenital anomalies, such as a Morgagni hernia (MH) and chest wall defect, is exceptionally uncommon. This report details a unique case of MH associated with an ipsilateral intercostal hernia in an adult, underscoring key diagnostic and surgical challenges.Case Presentation:A 71-year-old man with multiple comorbidities presented with acute abdominal pain and a right-sided chest wall bulge. Computed tomography revealed a large right lateral diaphragmatic and intercostal hernia between the right 9th and 10th ribs, with bowel loops protruding through the intercostal defect. The symptoms spontaneously improved, and repeat imaging showed a reduction of the hernia content. Thoracotomy revealed an omental herniation through an anteromedial diaphragmatic defect (MH) and a congenital chest wall defect with stretched intercostal muscles. The MH was primarily repaired using nonabsorbable sutures, and rib approximation was performed with absorbable sutures to address the chest wall defect.Clinical Discussion:This case is remarkable for the association of two congenital defects: an MH and a TDIH. Unlike typical posttraumatic TDIHs, the intercostal defect in this case stemmed from congenital chest wall maldevelopment. Preoperative diagnosis was challenging, with the MH initially missed on imaging. This emphasizes the importance of considering congenital variants in atypical hernias.Conclusion:To our knowledge, this is the first documented case of a TDIH occurring in conjunction with an MH, both likely congenital. Prompt recognition and tailored interventions are crucial for avoiding missed diagnoses and complications.

Neuromyelitis optica spectrum disorder (NMOSD) is a severe autoimmune disease that predominantly affects the optic nerves and spinal cord, which is a distinct disease process from multiple sclerosis (MS) and myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease. The most common neuro-ophthalmologic manifestation of NMOSD is atypical optic neuritis (ON), characterized by severe vision loss with a higher propensity toward bilateral involvement, longitudinal enhancement of the optic nerve, and chiasmal involvement than MS-related optic neuritis. Due to the severity of disease, high recurrence rate, and significant risk of permanent deficits, early recognition of neuro-ophthalmologic signs and short- and long-term management with immunosuppressive therapies is critical. In this article, we will review the characteristic neuro-ophthalmologic findings in NMOSD, serologic markers, neuroimaging findings, and current approaches to both acute and long-term treatment.

Type II endoleaks are a common occurrence after endovascular repair of aortic aneurysm, with a significant subset requiring treatment. There are a significant subset of type II endoleaks that are not amenable to established treatment routes, such as transarterial, transcaval, or translumbar. We report two cases of a successful transgraft approach to type II endoleak embolization using the Powerwire radiofrequency guidewire. The use of the radiofrequency guidewire to accomplish transgraft embolization has not been previously reported. This is a useful technique to have in the arsenal for treating type II endoleaks.