Perceived leg length discrepancy (pLLD) is a common source of dissatisfaction after total hip arthroplasty (THA), even in the absence of significant radiographic discrepancies. While spinopelvic factors have been increasingly recognized, most previous studies have focused on sagittal alignment or lumbar mobility, and the impact of preoperative global spinopelvic coronal flexibility on pLLD has remained unclear. We retrospectively reviewed 114 patients who underwent primary unilateral THA for osteoarthritis between January and December 2023. pLLD was assessed using a four-point scale at 6 months postoperatively. Patients who reported no perception of discrepancy were classified as the non-pLLD group, while those reporting mild, clear, or strong perception were grouped as the pLLD cohort. Preoperative spinal flexibility was measured on coronal radiographs during maximal lateral bending, calculating changes in spinopelvic angle (ΔSPA), reflecting thoracic-to-pelvic coronal flexibility, and lumbosacral angle (ΔLSA), reflecting lumbar-to-pelvic coronal flexibility. Secondary parameters included radiographic leg length discrepancy, leg lengthening, and sagittal spinopelvic alignment. Multivariable logistic regression analysis was used to identify independent predictors of pLLD. pLLD was reported in 47 patients (41.2
The trigeminal nerve, the largest cranial nerve, has both sensory and motor fibers responsible for facial sensation and mastication. This article reviews the anatomy, clinical examination, and imaging findings of the trigeminal nerve, followed by an overview of its major disorders, including trigeminal neuralgia, painful trigeminal neuropathy attributed to herpes zoster, trigeminal postherpetic neuralgia, and trigeminal autonomic cephalalgia. Recent advances in neuropeptide research have identified calcitonin gene-related peptides (CGRP) and pituitary adenylate cyclase-activating polypeptides (PACAP) as the key molecular targets for trigeminal nerve associated migraine therapy. Moreover, emerging evidence suggests that the MERTK-Galectin-3 signaling pathway may contribute to the pathophysiology of cluster headaches and peripheral sensitization. The discovery of robust circadian rhythms within the trigeminal ganglion further highlights the potential association between headache chronobiology and the timing of drug administration, suggesting a novel concept of chronotherapy in headache management. Collectively, these findings further our understanding of the trigeminal system from anatomical, molecular, and chronobiological perspectives, and may lead to more targeted and time-sensitive therapeutic approaches for primary headache disorders.
Background Platypnea-orthodeoxia syndrome (POS) causes posture-dependent hypoxemia due to right-to-left shunt, and it may be underestimated by routine evaluation. Case Summary An 84-year-old woman developed oxygen-refractory, posture-dependent hypoxemia during facial cellulitis and after contracting COVID-19. Transesophageal echocardiography identified a large patent foramen ovale with dynamic right-to-left shunt. Provocative assessment using invasive oximetry under a semi-sitting position and abdominal compression demonstrated a decrease in pulmonary-to-systemic flow ratio from 0.66 to 0.59. Because an intrahepatic inferior vena cava with focal narrowing rendered transcatheter closure infeasible, urgent surgical patent foramen ovale closure was performed, resulting in rapid improvement in oxygenation. Discussion Dynamic, flow-driven POS may be underestimated by routine evaluation, and provocative assessment is essential in guiding urgent surgical closure when transcatheter intervention is infeasible. Take-Home Messages Provocative transesophageal echocardiography and invasive oximetry can identify POS when routine evaluation is inconclusive. Surgical closure should be considered when transcatheter closure is anatomically infeasible.
Post-transplant relapse remains a major cause of treatment failure in adult B-cell acute lymphoblastic leukemia (ALL). The introduction of inotuzumab ozogamicin (InO) and blinatumomab (Blina) has expanded salvage options; however, their impact on outcomes and safety in patients relapsing after allogeneic stem cell transplantation has not been fully defined. To evaluate the impact of the availability of InO and Blina on clinical outcomes in adult B-cell ALL patients with post-transplant relapse, and to assess the safety of these agents in the post-transplant setting. We retrospectively analyzed 150 adult patients with B-cell ALL who relapsed after the first allogeneic stem cell transplantation. Patients were divided according to the time of their post-transplant relapse based on the approvals of InO and Blina in Japan: the pre-InO/Blina group (n = 95) and the post-InO/Blina group (n = 55). Outcomes were analyzed separately for Philadelphia chromosome (Ph)-negative and Ph-positive ALL. Overall survival (OS) after post-transplant relapse, complete remission (CR) rates as the best response before a second transplantation or last follow-up, and outcomes after a second transplantation were compared between groups. Adverse events associated with post-transplant use of InO and Blina were also evaluated. Among 95 patients with Ph-negative ALL, outcomes were significantly better in the post-InO/Blina group than in the pre-InO/Blina group, with the 2-year OS after post-transplant relapse improving from 19% to 51% (P = .003) and, among 88 treated patients, the CR rate increasing from 36% to 77% (P < .001). Multivariable analyses identified the time of post-transplant relapse and disease status at the first transplantation as independent prognostic factors for OS. Among 43 patients who underwent a second transplantation, the 2-year OS after second transplantation improved from 27% in the pre-InO/Blina group to 55% in the post-InO/Blina group (P = .029). In contrast, among 55 patients with Ph-positive ALL, OS after post-transplant relapse did not differ between groups. Among 32 patients treated with InO after post-transplant relapse, no patient developed veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) during InO therapy; however, 5 of 17 patients (29%) who subsequently underwent the second transplantation developed VOD/SOS. An interval of <2.5 months between InO and the second transplantation was associated with a higher VOD/SOS risk (56% versus 0%, P = .029). Among 30 patients treated with Blina, cytokine release syndrome occurred in 53% (grade 3 to 4, 7%) and immune effector cell-associated neurotoxicity syndrome in 13% (grade 3, 3%), with no fatal events. The prognosis of adult Ph-negative B-cell ALL after post-transplant relapse improved substantially in the post-InO/Blina era, including improved survival after a second transplantation. Overall, the safety profiles of InO and Blina in the post-transplant setting were acceptable, although VOD/SOS remains an important concern in patients proceeding to a second transplantation after InO.
