Previous research suggests a decline in body mass index (BMI) among older adults is associated with negative health outcomes, including mild cognitive impairment (MCI) and incident dementia . However, few studies have examined BMI longitudinal trajectories and how they change after MCI diagnosis among older African Americans. To characterize trajectories of change in BMI among older African American participants with no cognitive impairment at baseline we used data from the Minority Aging Research Study, MARS . We constructed piecewise linear mixed-effects models that included a random intercept and two random slopes. The first slope began at baseline. The second slope began at MCI diagnosis allowing for acceleration in the rate of decline after the diagnosis. The results showed BMI declined over time , and there was a faster decline after MCI . In a second model controlling for age, higher education was associated with a lower BMI at baseline  but slower decline before MCI . However, after MCI the decline of participants with higher education was faster . These results suggest an accelerated decline in BMI following MCI diagnosis, with higher education related to an even faster BMI decline, possibly a consequence of cognitive reserve.


Humans require a plethora of higher cognitive skills to perform executivefunctions, such as reasoning, planning, language and social interactions, whichare regulated predominantly by the prefrontal cortex. The prefrontal cortexcomprises the lateral, medial and orbitofrontal regions. In higher primates, thelateral prefrontal cortex is further separated into the respective dorsal andventral subregions. However, all these regions have variably been implicated inseveral fronto-subcortical circuits. Dysfunction of these circuits has beenhighlighted in vascular and other neurocognitive disorders. Recent advancessuggest the medial prefrontal cortex plays an important regulatory role innumerous cognitive functions, including attention, inhibitory control, habitformation and working, spatial or long-term memory. The medial prefrontal cortexappears highly interconnected with subcortical regions  and exerts top-down executive control over various cognitivedomains and stimuli. Much of our knowledge comes from rodent models usingprecise lesions and electrophysiology readouts from specific medial prefrontalcortex locations. Although, anatomical disparities of the rodent medialprefrontal cortex compared to the primate homologue are apparent, current rodentmodels have effectively implicated the medial prefrontal cortex as a neuralsubstrate of cognitive decline within ageing and dementia. Human brainconnectivity-based neuroimaging has demonstrated that large-scale medialprefrontal cortex networks, such as the default mode network, are equallyimportant for cognition. However, there is little consensus on how medialprefrontal cortex functional connectivity specifically changes during brainpathological states. In context with previous work in rodents and non-humanprimates, we attempt to convey a consensus on the current understanding of therole of predominantly the medial prefrontal cortex and its functionalconnectivity measured by resting-state functional MRI in ageing associateddisorders, including prodromal dementia states, Alzheimer’s disease,post-ischaemic stroke, Parkinsonism and frontotemporal dementia. Previouscross-sectional studies suggest that medial prefrontal cortex functionalconnectivity abnormalities are consistently found in the default mode networkacross both ageing and neurocognitive disorders such as Alzheimer’sdisease and vascular cognitive impairment. Distinct disease-specific patterns ofmedial prefrontal cortex functional connectivity alterations within specificlarge-scale networks appear to consistently feature in the default mode network,whilst detrimental connectivity alterations are associated with cognitiveimpairments independently from structural pathological aberrations, such as greymatter atrophy. These disease-specific patterns of medial prefrontal cortexfunctional connectivity also precede structural pathological changes and may bedriven by ageing-related vascular mechanisms. The default mode network supportsutility as a potential biomarker and therapeutic target for dementia-associatedconditions. Yet, these associations still require validation in longitudinalstudies using larger sample sizes. Jobson et al. convey that the medial prefrontal cortex functional connectivity inman exhibits disease-specific alterations across dementia associated disorders.These abnormalities appear to precede structural changes and may be driven byageing-related vascular mechanisms. This mainly affects the large-scale defaultmode network, thus providing potential biomarkers and therapeutic targets.  Greater understanding of the significance of the prefrontal cortex (PFC) is probablyowed to the serendipitous discovery after the unusual accident suffered by PhineasGage in 1848. The iron-tamping rod he had used on the railroad had pierced throughhis orbitofrontal lobe and changed him forever from once a respectable family manquickly into an ill-tempered irrational individual. We now know that a plethora ofhigher cognitive skills in order to perform crucial executive functions, such asreasoning, planning, language and social interactions, are regulated predominantlyby the PFC which contains the orbitofrontal region.Brodmann gave the first topographical description of the ‘frontal’ and‘precentral’ regions of the primate frontal lobe, which possessed adefinitive granular pyramidal layer IV as a prominent characteristic. Although theanterior cingulate cortex (ACC), which contains agranular   needed to performvarious complex cognitive tasks.,Electrophysiological evidence in rodents recording multiple single cells usingtetrodes has equally resulted in a mixed picture of changes in neuronal ensemblefiring rates and patterns in that only a few mPFC neurons discharge spatialworking memory transient signals differently during delay periods of maze tasks,with some cell assemblies predicting spatial locations.Non-human primate studies have instead largely suggested the dlPFC is essentialfor working memory, as early influential lesion studies exhibited evidence thatdlPFC damage, particularly involving the principal sulcus  is a key executivefunction mediated by the PFC and can be defined as the ability to adaptbehaviour with changing environmental contingencies.,Set-shifting ability is typically assessed in the clinic by utilizing theWisconsin Card Sorting Test (WCST), which ultimately involves a shiftingresponse by the individual switching their attention between variable perceptualcategories based upon changing card-sort rules.,Set-shifting procedures have additionally been modified for testing ofstructure–function relationships in rodents with substantial similarityto non-human primates. For example, Birrell and Brown designed a seminalset-shifting task for rats, which included extra-dimensional, intra-dimensionaland reversal learning stages akin to the monkey version. However, findings inrats were different from those in monkeys because mPFC lesions demonstratedsimilarly impaired extra-dimensional set-shifting, whilst ACC lesions impairedintra-dimensional set-shifting.,Human studies assessing cognitive flexibility processes have largely implicatedsimilar PFC subregions compared to the animal literature, thus emphasizing thesuitable translatability of the models. Specifically, individuals largely withdlPFC and mPFC damage have reported difficulties performing set-shifting duringthe WCST, such as inabilities to switch to a new rule as well as random andperseverative errors.,,,,,,Lesion studies of the mPFC have also been shown to play a role in impairedreversal learning, specifically when rodents are presented with complex imagesusing touchscreens.,,,,As with other domains of executive function, attention is a complex cognitiveprocess with various components that seem to depend on differing PFC subregions.Attention enables the brain to allocate sensory resources efficiently for theimmediate goal whilst ignoring alternative irrelevant inputs.The apparent agreement of findings from rodents to humans is perhaps undeniableas the 5-CSRTT was initially developed by Carli et al.,,It has been debated over several years whether rodent mPFC studies are relevant todefine human dlPFC functions, whilst others have suggested that rodent mPFC mightbetter represent the ACC.,Animal behavioural tasks of cognition adapted from human versions have enableddetailed investigation of brain areas by utilizing naturalistic paradigms. However,limitations arise if factors are not controlled such as food restriction, lack ofmotivation, susceptibility to stress and malaise or sense/locomotor impairments,which may be apparent for the prior studies analysing executive functions. Beforeanimals perform behavioural tasks, it may therefore be necessary to ensure that theycritically assess the cognitive function under investigation precisely, asexemplified by modified T-maze or operant procedures developed for working memory orcognitive flexibility respectively.,,In man, there is a clear deterioration in cognitive function during normal ageing,often with an observable reduction in information processing speed, which is notdependent on executive functioning.Studies utilizing rodent models have thus not only suggested that mPFC cognitivefunctioning is substantially affected by ageing in seemingly complex ways but haveadditionally aided in elucidating the underlying pathophysiology ofageing-associated neurological disorders that are susceptible to dementia.Specifically, authors demonstrated with a photothrombosis model   that revealed significant differences between ageing anddementia-associated disorders in terms of mean connectivity to brain regionsinvolving the mPFC. The current data present 41 published studies totalling 2473subjects with an average of 60 per study . The mos,There is a consistent decrease in mPFC–PCC FC in healthy aged individuals. Althoug,,,Furthermore, the PCC-insula reduced FC association has been positively correlatedto cognitive tests including those for executive function, along with decreasedFC with ageing in ACC connections to the insula as part of the salience network , which is predominantly characterized by executivedysfunction. Indeed, svMCI subjects exhibit significant declines in numerousDMN-associated regions compared to controls, which may result structurally fromsubcortical WM lesions that directly and indirectly impair fibre tractsessential for transmitting cerebral FCs. These regions specifically include thePCC/precuneus, mPFC, ACC, hippocampus, parietal cortices and superior frontalgyrus/middle frontal gyrus.,,,Approximately 30% of elderly stroke survivors develop delayed dementia(known as post-stroke dementia), with most cases closely resembling criteria forVaD diagnosis.,,,,However, lowered mPFC/ACC-precuneus FC was conversely demonstrated by utilizingsimilar group ICA/region-of-interest methodologies and rather reflects theimpact upon structural damage facilitating cognitive disturbances as adisconnection syndrome.,,Parkinson’s disease as a neurodegenerative disorder is typicallycharacterized by progressive motor dysfunction, but patients also show cognitivedecline with executive deficits, memory impairment and often dementia inadvanced stages.,,,However, similar disparities in trends as demonstrated in the prior vascularstudies, are prevalent within the Parkinson’s disease studies. As mPFC FCchanges compared to controls did not appear in two studies, which instead onlyshowed significant FC decreases that associated with cognitive performance orlower GM volume  structurally between the precuneus/PCC and subcortical/motor areas ormedial temporal gyrus.,,Despite stringent Parkinson’s disease clinical criteria, there remains asubstantial misdiagnosis rate with atypical Parkinsonian disorders (APDs), suchas multiple system atrophy (MSA) and progressive supranuclear palsy (PSP), eventhough APDs account for 10–20% of Parkinsonism subjects.The most common form of FTD is the behavioural variant, which has previously beenshown to account for approximately half of all frontotemporal lobar degeneration. Learning and plasticity are supported and shaped byneurotransmitter systems in the brain. Cholinergic neurotransmission playsimportant roles in synaptic plasticity, glial remodelling and the regulation ofinflammation. In addition, dopamine, and tonic GABAergic signallingNevertheless, it is still arguably difficult to ascertain confidently that the FCdysfunctions  are valiThe role of the mPFC within cognition, ageing and dementia is diverse, yet seeminglyfundamental for a range of critical cognitive operations. Animal work utilizinglesions and electrophysiology paired with behavioural tasks has refined ourunderstanding by demonstrating precise mPFC subregions perform distinct executivefunctions. However, much of the equivalent rodent functions lack direct anatomicalhomology to primates, which implicates the lPFC instead. Such a disparity mayreflect inconsistencies in mPFC terminology across studies as well as inadequaciescontrolling cognitively influential factors; therefore, further clarification of PFCterminology and rs-fMRI methodologies across the field is likely necessary.Moreover, rodent models of ageing have exhibited substantial decline in the abilityto perform tasks assessing mPFC-related executive functioning. Whilst rodent modelsof dementia-associated pathophysiological processes in PIS, VaD as well asadditional neurodegenerative disorders have distinguished crucial inabilities toperform several behavioural paradigms tasking the mPFC. Studies examininglarge-scale brain connections have comprehensively shown that the mPFC’slinks to heteromodal brain areas are integral for effectively coordinating numerousyet explicit cognitive paradigms, with the DMN exemplifying an extensively reportedinterconnectivity network that contains the mPFC as one of its central nodes.Existing rs-fMRI studies implicate mPFC FC variances during ageing anddementia-linked conditions between pairwise regions and globally within large-scalenetworks. Aberrations involving the DMN anterior and posterior sub-systems have beenpersistently reported across disorders, along with distinct patterns ofneuropathological changes that may preclude structural defects and subsequentcognitive deterioration. In addition, some findings remain uncertain within thedisorders due to methodological or sample inconsistencies, future validation couldthus enable translation into effective biomarkers for earlier diagnosis ortherapeutic intervention against pathological cognitive decline.Accordingly, future work is essential for deciphering if the identified trends ofreorganized FC intensity across disorders remain by replicating the rs-fMRIprotocols whilst utilizing larger cohort sample sizes, which likely would remove anyconfounding effects of detected chance observations. Future rs-fMRI studiestargeting the mPFC should also be conducted upon a longitudinal basis, which wouldenable a clearer understanding of how the disorders progressively worsen cognitionthrough modifying mPFC FCs over the entire clinical course of an individual’slifetime. This would clarify the remaining knowledge gap concerningstructure-functional relationships and if FC changes definitively precede or evenaugment atrophy of the GM and WM tract changes, thereby further elucidating theunderlying pathophysiological sequalae of these disorders. Moreover, conductingfuture rs-fMRI studies that focus specifically upon the impact of ageing anddementia-associated disorders within PFC-associated networks other than the DMNwould better clarify how this important region is more broadly affected. Perhaps,future studies should also have a closer selection of individuals with comparablecognitive performances and clinical features that may further remove any patientheterogeneity effects responsible for divergent results. Detailed biochemical andmolecular biology assessment of circuit-level receptors responsible mechanisticallyfor the mPFC connectivity alterations would be most helpful, perhaps through use ofagonists/antagonists targeting these receptors within rodent models, thereby furtherenabling the elucidation of refined pharmacological targets as a therapeuticintervention. Ultimately, use of network-based techniques may reconcile differencesthat remain within the field of mPFC cognitive function across species from a globalintegrated perspective by surveying the entire PFC and brain as a whole. Suchdeductions are particularly important considering the FCs between the mPFC withextra-frontal areas including the dlPFC are consistently implicated as necessary forcognition within both health and disease states.Data sharing is not applicable to this article as no new data were created oranalysed. The summarized data incorporated in the review are however available inBrain Communications online.This work was supported by previous grants from the Alzheimer’s Research UK(ARUK PG2013–22) and Medical Research Council, UK .The authors report no competing interests.fcab125_Supplementary_DataClick here for additional data file.


Background Despite the development of geriatrics surgery process quality indicators (QIs), few studies have reported on these QIs in routine surgical practice. Even less is known about the links between these QIs and clinical outcomes, and patient characteristics. We aimed to measure geriatrics surgery process QIs, and investigate the association between process QIs and outcomes, and QIs and patient characteristics, in hospitalized older vascular surgery patients. Methods This was a prospective cohort study of 150 consecutive patients aged ≥ 65 years admitted to a tertiary vascular surgery unit. Occurrence of geriatrics surgery process QIs as part of routine vascular surgery care was measured. Associations between QIs and high-risk patient characteristics, and QIs and clinical outcomes were assessed using clustered heatmaps. Results QI occurrence rate varied substantially from 2% to 93%. Some QIs, such as cognition and delirium screening, documented treatment preferences, and geriatrician consultation were infrequent and clustered with high-risk patients. There were two major process-outcome clusters: (a) multidisciplinary consultations, communication and screening-based process QIs with multiple adverse outcomes, and (b) documentation and prescribing-related QIs with fewer adverse outcomes. Conclusions Clustering patterns of process QIs with clinical outcomes are complex, and there is a differential occurrence of QIs within older vascular surgery patients, suggesting process QIs alone may be unreliable targets for quality improvement. Prospective intervention studies are needed to understand the causal pathways between process QIs and outcomes to help prioritize care processes that are most clearly linked to improved outcomes.


This session will provide updates on how the pandemic led to horrific situations in long-term care facilities and how the pandemic influenced major federal efforts to address elder abuse, neglect, and exploitation.


Peripheral arterial disease (PAD) is a vascular condition disproportionately affecting adults > 60 and the leading cause of disability for adults > 50. Because PAD is marked by severe leg pain and sometimes lower extremity amputation, quality of life (QOL) and wellbeing may be compromised however, we understand little about these constructs in this population. Furthermore, surgical care providers lack a comprehensive understanding of how individuals think about wellbeing and what is important to individuals during surgical care. We conducted a qualitative photographic elicitation study (n = 60) in one academic multidisciplinary PAD clinic to understand specific aspects of QOL of older individuals with PAD. Guided by interpretive description, a methodology pioneered in nursing, we analyzed data within and across five clinical symptom severity categories to examine for QOL constructs, impact on everyday life, understanding of disease, and desired treatment. Results demonstrate that individuals do not fully understand PAD diagnosis or its implications . Disease-specific knowledge was prevalent among patients experiencing lower extremity amputation but those suffering from wounds or gangrene had limited understanding. Furthermore, patients’ descriptions of QOL conflicted with the conceptualization of QOL in clinical practice and research. That is, many participants describe QOL based on activities they are capable of performing despite limitations. Results demonstrate the need for integrating gerontological knowledge into clinical care to improve quality of care for older adults.


Pennisetum glaucum) is a staple cereal crop for semi-arid regions. Its whole genome sequence and deduced putative gene sequences are available. However, the functions of many pearl millet genes are unknown. Situations are similar for other crop species such as garden asparagus , chickpea (Cicer arietinum) and Tartary buckwheat (Fagopyrum tataricum). The objective of the data presented here was to improve functional annotations of genes of pearl millet, garden asparagus, chickpea and Tartary buckwheat with gene annotations of model plants, to systematically provide such annotations as well as their sequences on a website, and thereby to promote genomics for those crops.Pearl millet  counterparts identified by BLASTX. Conserved domains in protein sequences of those species were identified by the HMMER scan with the Pfam database. The resulting data was deposited in the figshare repository and can be browsed on the Terse Genomics Interface for Developing Botany (TGIF-DB) website (http://webpark2116.sakura.ne.jp/rlgpr/).Sequences of genomes and transcripts of pearl millet, garden asparagus, chickpea and Tartary buckwheat were downloaded from a public database. These transcripts were associated with functional annotations of their  Pennisetum glaucum) is a staple cereal crop for semi-arid regions. Its whole genome was sequenced and putative gene sequences were deduced [Asparagus officinalis), chickpea (Cicer arietinum) and Tartary buckwheat (Fagopyrum tataricum) [Arabidopsis thaliana and rice (Oryza sativa) are dicot and monocot model species, respectively, and have better functional annotations for each gene  sequences that were deduced from the genome sequences of pearl millet, garden asparagus, chickpea and Tartary buckwheat as well as genome annotation files in the general feature format (GFF) were downloaded from the International Pearl Millet Genome Sequencing Consortium (IPMGSC) website , the Asp Arabidopsis or rice.Some proteins of the species used do not appear to have conserved domains and/or any close homolog in eitherSome pearl millet genes have been characterized by targeted analyses (,3; for e


Research suggests that social resources positively influence the health and well-being of lesbian, gay, bisexual, and transgender (LGBT) aging adults, but their access to social resources may vary according to LGBT identity. Using data from Aging with Pride: National Health, Aging, and Sexuality/Gender Study , multivariate models tested how access to social resources varied by LGBT identity and whether the effect of LGBT identity showed additional variations by sociodemographic characteristics  among aging LGBT adults. Lesbian respondents had larger social networks than gay respondents, while gay respondents had smaller networks than transgender respondents. Lesbian respondents had more social support and community belonging than other identity groups. Bisexual male respondents and transgender respondents had less support than gay respondents and bisexual male respondents reported less community belonging than gay respondents. Education and age moderated the association between LGBT identity and social support. Findings highlight the importance of considering social support separately from social network size with the understanding that large social networks do not necessarily provide ample social support and this distinction was particularly relevant for transgender respondents who had larger social networks, but less social support than gay respondents. Results also suggest that feelings of LGBT community belonging vary among LGBT identity groups. Health and human service professionals should not only consider the sexual and gender identity of their aging LGBT clients, but also consider the clients’ additional sociodemographic characteristics when assessing their access to social resources.


Personal social networks play a fundamental role in the daily lives of older adults. Although many studies examine how life course factors and personal preferences shape network formation, fewer consider how the places in which older adults live present opportunities and obstacles to cultivate social relationships. In the present study, we explore how geographic context is associated with the ability to interact with non-overlapping social groups within one’s personal network . This unique network formation offers older adults access to diverse social stimuli, non-redundant information, and social autonomy. By analyzing data from the Person-to-Person Health Interview Survey (N=709), we found that a minority of respondents reported the ability to bridge social groups within their networks. Respondents residing in rural and semi-rural counties engaged in fewer non-overlapping social groups compared to those residing in urban counties. These findings suggest that the communities in which older adults live condition opportunities for accessing unique social resources. Identifying the link between geographic residence and personal network structure has important implications for how individuals navigate the uncertainty and elevated support needs of later life. Additional research adopting a social network perspective is needed to provide insight into geographic health disparities occurring among the older population.


Middle-aged and older adults with mental health conditions have a high likelihood of experiencing comorbid physical health conditions, premature nursing home admissions, and early death compared with the general population of middle-aged and older adults. An emerging workforce of certified older adult peer support specialists aged 50 years or above is one of the fastest growing mental health workforces and may be a suitable community-based workforce to simultaneously support the mental health, physical health, and aging needs of middle-aged and older adults with a serious mental illness. Older adult peer support specialists are people with a lived experience of aging into middle age and older adulthood with a mental health condition. This presentation will present three single-arm pilot studies examining how certified older adult peer support specialists’ incorporate technology, including text messaging, ecological momentary assessments, and smartphone applications into practice and clinical outcomes among older adults with serious mental illness.


Increasing research points to the relevance of educational attainment for positive emotional experiences and physical functioning across adulthood. However, little is known about how age-related developments in positive affect and physical functioning differ by educational attainment. This study used longitudinal data of 10,893 individuals (60–80 years) from the Health and Retirement Study to examine whether educational attainment moderates trajectories of positive affect and physical functioning and their interrelations over 12 years. Initial results from multiple-group bivariate growth models revealed that individuals with less formal education have lower positive affect and poorer physical functioning at baseline. There was, however, no evidence that longitudinal changes in positive affect, longitudinal changes in physical health, and coupled changes between both variables varied with educational attainment. These initial findings suggest that lower educational attainment is primarily related to lower levels of positive affect and physical functioning, but not to greater age-related declines or their interrelations.


This symposium brings together four papers that address racial health disparities by investigating stressful aspects of social relations at different points in the life course. Cleary and colleagues focus on racial disparities in psychological health by testing cross-sectional effects of intergenerational stress over time. In particular, they investigate effects of network composition on the relationship between mothers' stressors and their children's depressive symptoms at three time points over 23 years. Camacho and colleagues use longitudinal data from the National Social Life, Health and Aging Project to examine cognitive decline among U.S. African-American, Latino, and White adults aged 60 and above. Results indicate loneliness predicted greater global cognitive decline over time in all groups. However, race differences in this association were found across cognitive function domains. Turner and colleagues consider dementia caregiving challenges among non-Hispanic Blacks. Data from five focus groups were analyzed to reveal distinctive challenges to caregiver health during the COVID-19 pandemic including increased burden and barriers to service access. Finally, Sol and colleagues examined the bidirectional association between loneliness and self-rated health over time among a racially diverse sample. Findings illustrate racial patterns in how loneliness at midlife influences health in later life. Antonucci will discuss the role of stress from social relations as a means to fully understand racial disparities in health across the life course.


It remains challenging to quantify the pace of aging across lifespan due to lack of comprehensive longitudinal measurements across wide range of age. In Baltimore Longitudinal Study of Aging, we have measured the longitudinal trajectories of more than 30 phenotypes across four pre-identified domain - body composition, energy regulation, homeostatic mechanisms and neurodegeneration/neuroplasticity, among participants with age between 20+ and 90+. We implemented a two-stage approach to summarize the longitudinal trajectories of these phenotypes across four domains into a summarized score. We demonstrated that higher summarized score  is associated with slower decline in both cognitive and physical functions, across different stages of adulthood. Our results imply that deep longitudinal profiling contains rich information and may potentially replace diseases as an early endpoint in trials targeting at aging. Further, understanding the underpinning of longitudinal phenotypic trajectories may provide clues to the biological mechanisms of aging.


Antiphospholipid syndrome is an antibody mediated pro-thrombotic state leading to various arterial and venous thromboses. The syndrome can be either primary or secondary to other autoimmune diseases, commonly systemic lupus erythematosus. Cardiac involvement, in particular valvular disease is common in patients with antiphospholipid syndrome, occurring in about a third of these patients. Valvular diseases associated with antiphospholipid syndrome often occur as valve thickening and non-bacterial vegetation or Libman-Sacks endocarditis. Deposits of antiphospholipid immunoglobulin and complement components are commonly observed in the affected valves, suggesting an inflammatory process resulting in valvular vegetation and thickening. Libman-Sacks endocarditis has a high propensity towards mitral valve, although haemodynamically significant valvular dysfunction is rare.We present a successful aortic valve replacement with cardiopulmonary bypass in a 48 years old lady with antiphospholipid syndrome, who has severe aortic regurgitation as a result of Libman-sacks endocarditis. Antiphospholipid antibodies were positive and the clinical data showed both negative cultures and infective parameters. Surgically resected vegetations revealed sterile fibrinous and verrucous vegetations on aortic valve. Valve replacement and the course of cardiopulmonary bypass was uneventful, and the patient was discharged well.Classically Libman-Sacks endocarditis is often and more commonly associated with autoimmune diseases such as systemic lupus erythematosus, although it can occur in both primary and secondary antiphospholipid syndrome. It is not a common entity, and it is a frequent underestimated disease as most clinicians do not routinely screen for valvular lesion in patients with antiphospholipid syndrome unless they are symptomatic. However, due to its high prevalence of cardiac involvement, clinicians should have a high index of suspicion in the attempt to minimize cardiovascular and haemodynamic complications. Valve surgery in patients with antiphospholipid syndrome carries considerable early and late morbidity and mortality, usually caused by thromboembolic and bleeding events. The perioperative anticoagulation management and haemostatic aspect of antiphospholipid syndrome present an exceptional challenges to clinicians, surgeons, anaesthetists and laboratory personnel. Antiphospholipid syndrome (APS) is a rare coagulative disorder with antiphospholipid antibody mediated pro-thrombotic state mainly characterised by hypercoagulable complications. Cardiac manifestations of APS include arterial or venous thromboses, valve diseases, coronary artery disease, intracardiac thrombus, pulmonary hypertension and dilated cardiomyopathy, with the functional impairment of heart valves being the most common manifestation, which commonly associated with Libman-Sacks endocarditis. Libman-Sacks endocarditis, also known as non-bacterial thrombotic, verrucous, or marantic endocarditis, originally described in patients with systemic lupus erythematosus, is a well-known complication of APS. We present a successful aortic valve replacement in a 48 years old lady with aortic valve Libman-sacks endocarditis and APS who presented with acute pulmonary oedema.A 48 years old lady was admitted to cardiology ward complaining of progressively worsening breathlessness, orthopnoea and chest discomfort for 1 month. Coexisting medical conditions include chronic hypertension on treatment, with 2 episodes of spontaneous miscarriages previously and 1 episode of transient ischemic attack 3 years ago.Clinically, she was haemodynamically stable with a wide pulse pressure. Finger clubbing was noted with livedo reticularis rashes over bilateral upper and lower limbs without ulcers or thrombophlebitis. Her peripheral pulses were bounding with water-hammered pulse, and a grade III diastolic murmur was heard during cardiac auscultation. In addition, she has elevated jugular venous pressure, crepitation over both lung bases, and bilateral pedal oedema.2 was seen on aortic valve  and Erythrocyte sedimentation rate (ESR). Otherwise the reports were not suggestive of occult infection with normal white cell count, C-reactive protein (CRP), and negative blood cultures. D-dimer was positive but there was no features suggestive of deep venous thrombosis or pulmonary embolism. Further serological investigations revealed positive antinuclear antibody (1:640), Lupus anticoagulant (LA), anti-smith antibodies, direct and indirect coombs’ test. Subsequent bone marrow aspiration and cytogenetic study showed a grossly normal specimen. She was thus treated as acute pulmonary oedema secondary to severe aortic regurgitation, precipitating by aortic valve vegetation with newly diagnosed antiphospholipid syndrome. Therapeutic enoxaparin therapy was initiated perioperatively.She underwent aortic valve replacement, and intraoperative exposure of aortic valve revealed verrucous thickening of aortic leaflets with vegetations involving all three cusps, with rolled edge on left coronary cusp. No perforation or destruction of cusp tissue was identified. A mechanical valve was implanted following the excision of aortic valve. The course of cardiopulmonary bypass was uneventful. Subsequent microscopic findings of the valve specimen confirmed the diagnosis of Libman-Sacks endocarditis Fig. .Fig. 2EPostoperatively, oral anticoagulation therapy was started with international normalized ratio (INR) target of 2.5 to 3.5 with subcutaneous enoxaparin as bridging therapy. There was no excessive bleeding or major thromboembolic complications occurred during in-patient stay. Corticosteroid therapy was started at 2 months postoperatively by Hematology team. She was well and free of complications at 6 months and 1 year follow-up. Clinical examinations and echocardiography demonstrated satisfactory aortic valve function. The microbiological culture of the excised vegetations revealed sterile specimens.Antiphospholipid syndrome (APS) is a multi-system disorder of autoimmune aetiology. This syndrome is defined clinically by arterial and venous thrombotic events as well as recurrent pregnancy loss, with serologically positive antiphospholipid antibodies including lupus anticoagulant (LA) and anticardiolipin antibodies (aCL). It was originally described and most often found in patients with systemic lupus erythematosus (SLE), however, even patients without features of autoimmune disease may harbour antiphospholipid antibodies and suffer from thromboembolic events, thus leading to the distinction of primary and secondary APS. APS affects 2% of population and SLE is found in 40% of patients with APS . The preAPS comprises a wide array of clinical features such as venous and arterial thromboses, recurrent pregnancy loss and even thrombocytopenia. Heart valve disease is the most common cardiac manifestation in patients with APS, and it is defined in the absence of rheumatic and infective endocarditis. It was reported as high as 32–38% of valvular lesion occur in patients with APS by transthoracic echocardiography , 5. WhenThe role of antiphospholipid antibodies in the pathogenesis of Libman-Sacks endocarditis remained unclear, probably the result of autoimmune antibodies being directed against the negatively charged phospholipids on the endothelial membranes, either due to micro injuries secondary to stress or turbulence, or induction of autoantibodies by molecular mimicry caused by infectious agents , 10. MicPatients with APS often present with thromboembolic events from other systems rather than cardiac manifestation, most commonly cerebrovascular ischemic events, which is apparent in this case study where patient had transient ischemic attack years ago. These thromboembolic episodes might be due to direct effect of antiphospholipid antibodies or intermittent dislodgement of Libman-Sacks vegetations. Majority of valvular impairment associated with Libman-Sacks endocarditis are mild with minor insignificant haemodynamic disturbance without clinically overt disease , 14. OnlDiagnosing Libman-Sacks endocarditis often necessitates the exclusion of rheumatic valve disease and infective endocarditis. Most clinicians do not routinely screen for valvular lesion in APS patients unless the patient is symptomatic or in the presence of new murmur. Recently, the international consensus committee has revised the definition of APS associated cardiac valve lesion with the following criteria: Coexistence of laboratory criteria of APS along with echocardiography detection of lesions, and/or regurgitation and/or stenosis of mitral or aortic valve, with the defining valve lesions of thickness more than 3 mm, localized thickening involving the leaflet’s proximal or middle portion, and irregular nodules on the atrial face of the edge of the mitral valve, and/or the vascular face of the aortic valve . HoweverUnlike infective endocarditis where the valve needs to be completely excised to remove infected tissue, repair and preservation of the valve is possible in selected patients with Libman-Sacks endocarditis, thus eliminating the need for lifelong anticoagulation therapy. The indications for surgery remain dispute, and the outcomes of surgical valvular replacement have been limited to case reports or series. However, we agreed on the clear indications for surgical intervention, which include severe valvular dysfunction, large vegetations and recurrent embolization despite therapeutic anticoagulation. Furthermore, non-bacterial thrombotic endocarditis may have much greater surgical risk for vegetation embolization than infective endocarditis due to the risk of thromboembolism . To dateAortic valve replacement is deemed necessary due to severe valvular regurgitation causing significant symptomatic ventricular dysfunction. The selection of mechanical valve in this case was based on the existing unavoidable need for lifelong anticoagulation therapy. A mechanical valve may be theoretically more advantageous over a tissue valve considering the younger age of patients at the time of surgery in regards to the risk of structural valve deterioration, and the need for lifelong anticoagulation. However, the use of tissue valve has increased progressively over the years to allow for easier and safer monitoring and management of anticoagulation therapy, with regards to prevention of thromboembolic events and bleeding complications, compounded by the complex monitoring of anticoagulation due to presence of antibodies, and the possible coexisting thrombocytopenia . This isIt is well recognized that patients with APS undergoing surgical valve replacement surgery with cardiopulmonary bypass are at much greater risk of thrombotic and bleeding episodes. Perioperative management of patients with APS undergoing cardiac surgery is a major concern and remains challenging due to significant risk of thrombosis with the cessation of anticoagulation therapy; as well as bleeding secondary to excessive anticoagulation or coagulation factor deficiency . FurtherLibman-Sacks endocarditis is not a common entity and is frequently underestimated as majority valvular involvement in patients with APS are asymptomatic and often diagnose incidentally. It is difficult to detect Libman-Sacks endocarditis, and the diagnosis often requires strong clinical suspicion with exclusion of more common valve lesions such as rheumatic or infective endocarditis. We hope that this case study is able to emphasize Libman-Sacks endocarditis as a cause of valvular heart disease not only in systemic lupus erythematosus, but also in primary APS. Early detection and prompt treatment of valvular disease in APS may halt the progression of valvular dysfunction since valve replacement surgery in APS carries significant perioperative morbidity and mortality.


Twenty-eight states have provided nursing homes (NHs) with immunity from legal liability related to COVID-19. This study places these provisions in the context of prior actions protecting NHs from legal action and explores factors influencing the adoption of such immunity provisions across states. It uses cross-sectional data to examine patterns of policy adoption and to assess states’ likelihood of adopting immunity provisions using multivariate methods. Variables of interest include information on state political, socioeconomic, programmatic, and COVID-19-related characteristics as well as data on campaign contributions and lobbying activity at the state level. Factors significantly related to NH immunity provision adoption included measures of state fiscal health (unemployment), ideology (percent legislators Democrat), governing capacity (unified government), and NH characteristics . Population density and Medicaid as a percentage of state general fund expenditures proved significant as well. Against these complex influences, organizations lobbying on behalf of NH residents and their families have found themselves ineffectual in creating avenues for accountability. Results indicate that enforcing accountability for NH deaths during the COVID-19 pandemic is a complex process, constrained by available policy tools and made more complicated by factors external to the NH environment that contributed to high death rates. Historically, the NH industry has been successful in avoiding consequences for poor quality care, a pattern that has persisted in that NHs have generally been successful in avoiding liability for negligence during the COVID-19 pandemic.


Pregnant patients may present with multiple complex comorbidities that can affect peripartum management and anesthetic care. The preanesthesia clinic is the ideal setting for early evaluation of high-risk pregnant patients. Comorbidities may include cardiovascular pathology such as valvular abnormalities, septal defects, aortopathies, arrythmias and cardiomyopathies. Additional comorbidities include pulmonary conditions such as obstructive sleep apnea as well as preexisting neuromuscular and skeletal disorders that may impact anesthetic management. Hematologic conditions involving both bleeding diathesis and thrombophilias may present unique challenges for the anesthesiologist. Patients may also present with endocrinopathies including diabetes and obesity. While not as common, high-risk patients may also have preexisting gastrointestinal conditions such as liver dysfunction, renal failure, and even post-transplant status. Ongoing and prior substance abuse, obstetric conditions such as placenta accreta spectrum disorders, and fetal conditions needing ex utero Intrapartum treatment also require advanced planning. Preanesthesia evaluations also help address important ethical and cultural considerations. Counseling patients regarding anesthetic considerations as well as addressing concerns will play a role in reducing racial and ethnic disparities. Anticipatory guidance by means of pre-anesthetic planning can facilitate multidisciplinary communication and planning. This can allow for an impactful and meaningful role in the care provided, allowing for safe maternal care and optimal outcomes. While caring for pregnant patients, current anesthesia guidelines emphasize the importance of a communication system between obstetric providers, anesthesiologists, and members of multidisciplinary teams . Women aEarly evaluation of high-risk pregnant women in preanesthetic clinics can enable optimal care. Preanesthetic clinics facilitate comprehensive patient assessment and optimization and provide education regarding obstetric management and anesthetic options for labor and delivery . The AmeCardiovascular systemThe physiological changes of pregnancy can aggravate preexisting cardiac disease. Cardiovascular disease is a leading cause of maternal mortality. The severity of the maternal condition should not be underestimated and attributed to the “normal” symptoms of pregnancy . A multiPatients with cardiac disease typically fall into the following broad categories-congenital versus acquired, valvular (stenotic versus regurgitant), septal or shunt lesions, pulmonary hypertension, ischemic heart disease, cardiomyopathies, aortopathies and arrythmias. Risk stratification models may be used to determine the best hospital for antenatal management and delivery ,34. For Improvements in cardiac surgery have resulted in female babies with previously fatal congenital conditions surviving to reach sexual maturity . AcquireThe effects of valvular disease in pregnancy vary based on several factors including type of lesion and severity. Ventricular dysfunction due to regurgitant valves can lead to heart failure and arrhythmias. Aortic regurgitation during pregnancy can be tolerated in the absence of left ventricular dysfunction. Stenotic valves are typically more concerning and when combined with the decreased systemic vascular resistance and increased blood volume in pregnancy, it can lead to syncope and congestive heart failure respectively. Echocardiographic measurement of valve areas is usually preferred to flow gradients during assessment since the latter can be expected to increase in pregnancy because of increased cardiac output and may not give as accurate an assessment  . Mitral Mortality due to pulmonary hypertension remains high during pregnancy despite advanced therapies. Vaginal delivery under appropriate analgesia is generally recommended. To avoid a rapid decrease in systemic vascular resistance that can cause cardiopulmonary decompensation, incremental epidural-only anesthesia with careful titration of local anesthetics is suggested, as general anesthesia with positive-pressure ventilation could increase pulmonary vascular resistance and right-to-left shunt . GeneralHypertrophic obstructive cardiomyopathy is frequently inherited and presents with left ventricular outflow obstruction. Tachycardias, hypovolemia and vasodilatation are poorly tolerated. Peripartum cardiomyopathy is the development of heart failure in the last month of pregnancy or within five months of delivery . A smallFor patients with syndromic (e.g. Marfan’s syndrome) and non-syndromic (e.g. ACTA2 gene mutations) familial aortopathies, monitoring blood pressure, symptomatology and surveillance imaging should be done throughout pregnancy to reduce risk of aortic dissections ,39. For Creation of a delivery plan, discussion of anesthetic and analgesic options, and discussion regarding invasive hemodynamic monitoring are part of the preanesthetic evaluation. Patients with severe left-sided obstructive heart disease including coarctation of the aorta and stenotic valvular lesions, pulmonary hypertension, and cardiomyopathies may have particularly poor outcomes and difficulty tolerating labor, surgery, and anesthesia -35. HighFor most cardiac patients, vaginal delivery remains the safest option, barring obstetric indications for cesarean delivery. Vaginal delivery is associated with decreased blood loss and hemodynamic changes and reduced risk of thrombosis and infection . A “cardAnxiety and pain during labor can lead to increased afterload, decreased uteroplacental perfusion, and potential cardiovascular collapse. Neuraxial labor analgesia results in greater cardiopulmonary and hemodynamic stability and should be initiated as early as possible during labor.As mentioned, parturients with cardiac disease may require invasive monitoring that includes placement of arterial, central venous and pulmonary artery catheters and transthoracic echocardiography. Central venous access allows for infusion of vasoactive drugs . PulmonaRespiratory systemPregnant women with obstructive  or restrictive  lung diseases may be seen in the preanesthetic clinic . Asthma The physiological changes of pregnancy worsen sleep-disordered breathing, a spectrum of conditions of increasing severity from loud snoring to obstructive sleep apnea (OSA). All obstetric patients should be assessed for OSA as it increases the risk of adverse maternal, fetal, and neonatal outcomes . If OSA Cystic fibrosis patients begin pregnancy with mixed obstructive and restrictive lung disease, often with chronic lower respiratory tract infections . PulmonaRestrictive lung disease can occur secondary to intrinsic (e.g. sarcoidosis) or extrinsic (e.g. kyphoscoliosis) factors. Antenatal assessment should also include determination of respiratory reserve and functional status including exercise capacity testing and home oxygen requirements . Neurological, neuromuscular and skeletal disordersPregnant patients with neurological disorders  neuromuscular disorders  or musculoskeletal disorders  may also be encountered. Early consultation allows accurate documentation of any pre-existing neurological deficit and management. Delivery should be done in a tertiary care center with access to services such as neurology, neurosurgery, and radiology. Pregnant women with epilepsy face several challenges. Increased seizure frequency is observed in some due to the pharmacokinetic and hormonal changes of pregnancy. Anticonvulsant drug levels can decrease during pregnancy which is explained by decreased plasma protein binding and the greater drug clearance . MaternaMultiple sclerosis is a chronic autoimmune inflammatory demyelinating disease with an onset commonly occurring during the childbearing years. A lower relapse rate is thought to occur during pregnancy, with an increased relapse rate in the first three months postpartum. Patients should be counseled about this risk that exists irrespective of the type of anesthetic . AssessmArnold-Chiari malformations (ACM) are congenital anomalies in which the cerebellum herniates through the foramen magnum, displacing the lower pons and medulla. Of the four types described, type I is the most common. The condition is associated with an impaired flow of cerebrospinal fluid (CSF) from the fourth ventricle and dynamic or static herniation of brain tissue. It has been shown that cerebrospinal fluid pressure increases with uterine contractions by a mean of 2.5 mmHg, and that the elevation of intracranial pressure (ICP) is much greater during the second stage of labor. While neuraxial techniques have been found to be a safe and viable anesthetic option, correct interpretation of imaging tests and multidisciplinary input, including that of neurology and neurosurgery, should be elicited before deciding on anesthetic management in patients with known increases in ICP ,48.Women with cerebral aneurysms or intracranial space-occupying lesions  present unique peripartum challenges. For patients with unruptured cerebral aneurysms, while mode of delivery does not seem to alter the incidence of rupture, most women tend to undergo cesarean delivery . EpiduraIdiopathic or benign intracranial hypertension  is a common condition, characterized by raised intracranial pressure without related pathology in either the brain or the composition of cerebrospinal fluid. The main symptom is headache, and the cardinal sign is papilledema . TreatmeSpinal dysraphisms are neural tube closure birth defects that may be open or closed and are commonly seen in the lumbosacral area. In patients with surgically corrected open spinal dysraphisms, the terminal portion of the spinal cord typically lies at a vertebral level lower than normal. Dysraphisms may be inherently associated with the tethered cord syndrome. Patients often develop minor sensory, motor, and functional deficits of the lower limbs, bowel and bladder. Closed defects may or may not be associated with cutaneous stigmata. A tethered spinal cord has implications for neuraxial anesthesia with increased risk due to its association with a low-lying spinal cord, need for imaging, and often abnormal preanesthetic neurological status . If spinWith improvements in management and rehabilitation, more women with spinal cord injury are conceiving children. Women with spinal cord injuries may give birth vaginally. Patients with spinal cord injury at the level of T6 or above are at risk of developing autonomic hyperreflexia. Although pain perception is impaired in these women at or above T10, neuraxial anesthesia is the treatment of choice for pain arising from the pelvic organs. Early neuraxial labor analgesia is advisable. Continuous intraarterial blood pressure monitoring should also be considered during the peripartum period . Myasthenia gravis is an autoimmune disorder characterized by episodes of skeletal muscle weakness that are made worse by activity. The course of disease during pregnancy is highly variable. The maternal physiological changes of pregnancy may require adjustments in the doses of anticholinesterase drugs. Patients may experience progressive respiratory compromise secondary to diaphragmatic elevation during pregnancy. Preanesthetic evaluation should assess the extent of bulbar and respiratory involvement and overall baseline muscle strength. Pulmonary function testing should be done if there is respiratory compromise. Since the uterus consists of smooth muscle, the disorder generally does not affect the first stage of labor. The second stage of labor requires the use of striated muscle, so an assisted vaginal delivery may be required . Early nRare neuromusculoskeletal disorders that have multisystem manifestations include myotonic dystrophies, neurocutaneous syndromes like neurofibromatosis and tuberous sclerosis, and Guillain-Barre syndrome. In muscular dystrophies, cardiorespiratory involvement may be varied. Neuraxial techniques are preferred for labor analgesia and cesarean delivery. Severe disease may result in both airway and spinal abnormalities presenting challenges . In neurMusculoskeletal disorders including the inflammatory arthritides rheumatoid arthritis and ankylosing spondylitis can affect perioperative planning for the obstetric patient. Systemic manifestation involving the cardiovascular and respiratory system should be ruled out. Neuraxial anesthesia may also be technically challenging do to calcified interspinous ligaments and osteophyte formation limiting the patient’s ability to flex forward. Unexpectedly high blocks have been reported . ChallenScoliosis is a lateral deviation in the vertical axis of the spine with severity being determined by measurement of the Cobb angle. Most cases of scoliosis are idiopathic; however, some are associated with neuromuscular conditions such as myotonic and muscular dystrophies, Marfan’s syndrome, rheumatoid disease, osteogenesis imperfecta and achondroplasia. Pregnancy exacerbates the severity of the spinal curvature and cardiopulmonary abnormalities including restrictive lung disease and pulmonary vascular resistance. Neuraxial anesthesia may be offered, however it may be technically difficult with increased possibility of complications such as aberrant local anesthetic spread. Patients with achondroplasia are often delivered by cesarean delivery due to an inadequate maternal pelvis outlet with a normal-sized fetus. The small stature and spinal stenosis in these patients necessitate a reduction in the dose of local anesthetic required, therefore an epidural or combined spinal-epidural anesthesia may allow for better titration of the local anesthetic dose .Parturients who have had prior back surgeries may also have scar tissue or removal of the ligamentum flavum that could pose an anatomic challenge for epidural placement and for anesthetic administration . If a paHematological disordersCommon causes of thrombocytopenia during pregnancy include gestational thrombocytopenia, autoimmune  thrombocytopenic purpura, and hypertensive disorders of pregnancy. Gestational thrombocytopenia is a benign self-limiting condition and accounts for most of the thrombocytopenia seen during pregnancy . In most6/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors [If thrombocytopenia is discovered during pregnancy, an assessment of bleeding history and etiology is necessary. The risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 10 factors . For pat factors .Congenital coagulopathies include von Willebrand’s disease which is divided into several subtypes based on quantitative and qualitative defects in the von Willebrand factor (vWF), which binds to collagen at sites of vascular injury, mediates platelet adhesion and aggregation, and serves as a carrier protein for coagulation factor VIII. A hematology consultation should be obtained early in pregnancy. These parturients should be tested for functional VWF and factor VIII concentration, as low levels are often be treated prior to delivery with therapies including desmopressin and von Willebrand factor concentrates. Case series have demonstrated safe spinal, epidural, and combined spinal-epidural anesthesia, and neuraxial anesthesia is considered an option for patients with normalized VWF:RCo, factor VII, and VWF antigen concentrations .Common thrombophilias diagnosed in pregnancy include Factor V Leiden deficiency and protein C and S deficiency. ACOG has recommended thromboprophylaxis for pregnancies complicated by inherited thrombophilias, which present challenges for neuraxial anesthesia about which the patient should be counseled . The SocEndocrine disordersGestational diabetes accounts for the majority of women with diabetes, followed by type I diabetes and type 2 diabetes . MaternaPatients with obesity are at a higher risk of anesthetic and obstetric complications and should have a formal preanesthesia evaluation . A thoroPregnant women likely exhibit overt or symptomatic hypothyroidism at a much lower rate than nonpregnant women. However, the required replacement of thyroid hormone in clinically hypothyroid patients often increases during pregnancy and is titrated to serum TSH levels. Patients with hyperthyroidism are treated with methimazole and propylthiouracil. Radioactive iodine is contraindicated in pregnancy. Patients with severe, untreated hyper- or hypothyroidism may present with unexplained tachycardia (hyperthyroidism) or bradycardia (hypothyroidism), abnormal weight gain for gestational age, or a visible or palpable goiter . This caGastrointestinal disordersPregnant patients with chronic liver disease or end-stage liver disease who are pre-transplant are at increased risk for both obstetric and anesthesia-related complications . They arParturients with chronic kidney disease or end-stage renal disease are anemic, experience hemodynamic alterations and electrolyte imbalances and are at increased risk for gastric aspiration. Although uncommon, pregnancy has been reported in women undergoing hemodialysis . AnticoaSubstance abuse disordersTobacco and alcohol are among the most commonly used substances during pregnancy and can cause anesthetic complications in addition to their teratogenic effects . AnestheThere is a high prevalence of opioid use during pregnancy, with risks of maternal withdrawal, neonatal abstinence syndrome, and increased analgesic needs due to opioid intolerance or opioid-induced hyperalgesia . ParturiHigh-risk obstetric and fetus-related considerationsPatients with placenta accreta spectrum disorders benefit from an early preanesthetic consultation. These cases involve multidisciplinary care and coordination involving maternal-fetal medicine, gynecology-oncology, obstetric anesthesiology, urology, general and trauma surgery, interventional radiology and neonatology, with potential need for massive transfusion . The obsEx utero intrapartum treatment is a specialized surgical technique developed to establish cardiopulmonary support safely and efficiently at delivery while maintaining placental bypass. The technique involves planned partial delivery of the fetus via hysterotomy while maintaining uterine relaxation and placental support, allowing for the establishment of neonatal cardiopulmonary stability in a controlled manner . Early aWe have included the following tables for further guidance. Tables Anesthesiology consultations for complex obstetric patients foster optimal outcomes. They can help facilitate multidisciplinary care and enable shared decision-making. Furthermore, understanding the physiologic changes during pregnancy and the complex interplay between systemic comorbidities can improve the care provided. Finally, improved communication with patients regarding expectations, and anesthetic and peripartum planning can improve parturients’ satisfaction with their delivery experience and potentially reduce maternal morbidity and mortality.


Struvite stones represent the most common cause of the rapidly growing staghorn calculiwhose predisposing factors include female sex, stasis from urinary tract malformationsor obstruction, neurogenic bladder, among othersWe read with great interest the work of Danilovic et alThe authors found a similar frequency of metabolic abnormalities in 24-hour urine testsbetween groups, but only important for hypocitraturia. There was no significantdifference in new events between groups, and treatment of metabolic abnormalities amongpatients with MAP stones rendered them prone to the same risk for a new event as thosewithout any metabolic disturbance.2, especially concerninglower rates of urinary calcium, due to secondary hyperparathyroidism, as alreadydemonstrated in primary struvite urolithiasis populationsAlthough metabolic abnormalities in pure struvite stone formers indeed appear to be morecommon than previously reported, the profile of metabolic alterations differ amongreports. Iqbal et alNevertheless, the study by Danilovic et al


Hip dislocation after hip arthroscopy is an uncommon postoperative complication. We report a case of a 51-year-old woman who underwent right hip arthroscopy and presented with an anterior hip dislocation on postoperative day five. The index surgery involved capsulotomy, cam lesion debridement, and femoroplasty for an anterosuperior labral tear and cam-type femoroacetabular impingement. The patient underwent an uneventful recovery course until eight weeks postoperatively she developed iliopsoas bursitis. Her symptoms were managed conservatively with activity modification and physical rehabilitation. Complete resolution of symptoms was reported by the six-month follow-up visit, and no further dislocations or instability had been reported at 12 months. Anterior hip dislocation is a rare complication following hip arthroscopy and patients may experience persistent iliopsoas bursitis several months following successful reduction. Hip arthroscopy (HA) is a surgical procedure increasing in popularity in recent years due to its relatively low complication rate and less invasive approach compared to traditional hip surgery ,2. Hip dThe patient is a 51-year-old woman who underwent right hip arthroscopy with labral repair and femoroplasty with cam lesion debridement. After failing years of conservative management for unremitting right hip and groin pain, she elected to undergo right hip arthroscopy. Following surgery, she was made partially weight-bearing with an early range of motion to assist in recovery. She experienced an uneventful postoperative course until day five. While cleaning her kitchen, she extended and externally rotated her operative leg resulting in sudden and severe right hip pain accompanied by a fall to the ground and an inability to bear weight.Upon presentation, her right leg was shortened and externally rotated with intact neurovascular function. Radiographs revealed right anterior hip dislocation without evidence of acute fracture Figure .She was consciously sedated, closed reduced, and placed in a knee immobilizer Figure .Postreduction computed tomography (CT) revealed an impaction-type fracture in the anterior aspect of the femoral head Figure .Magnetic resonance imaging (MRI) was also obtained, which revealed an impaction fracture involving the anterior margin of the right femoral head and neck junction Figure .Surgical pathology of the cam resection and femoroplasty ruled out the presence of bony pathology. By one week postoperatively, she was able to ambulate with a walker. Physical examination revealed painless hip flexion greater than 100 degrees, extension to neutral, internal rotation to 35 degrees, and abduction to 45 degrees. However, she still experienced a sensation of anterior hip popping and had crepitus anteriorly. Initial MRI and CT scan were re-reviewed, and the labral repair appeared to be intact. She was advised to limit external rotation and hyperextension of the hip with protected weight-bearing and crutch use.By six weeks postoperatively, her preoperative anterior hip popping and crepitus had entirely resolved. She experienced no pain in the anterior hip capsule and no apprehension with hyperextension or external rotation. The patient had a stable gait without the use of assistive devices and was able to perform a full crouch without difficulty.The patient did not remain symptom-free during her continued follow-up visit. By eight weeks postoperatively, she experienced a re-intensification of her right hip pain that she characterized as a deep ache in the joint. Her hip occasionally locked and was accompanied by a sense of instability. She denied a history of trauma - other than the recent hip dislocation - or inciting events. Physical examination revealed palpable crepitus in the anterior acetabular margin at 60 degrees to 90 degrees of flexion. Both internal and external rotation aggravated these symptoms. The patient could ambulate, although she preferred to take small steps with her right lower extremity to reduce pain. Radiographs of the right hip revealed a well-maintained joint surface and joint line architecture with no gross bony abnormalities.Subsequent MRI revealed right iliopsoas bursitis with filling defects in the joint recesses and the iliopsoas bursa suspicious for synovial proliferation and small intra-articular bodies Figure .Additionally, new-onset small focal cartilage loss and osteochondral impaction injury in the femoral head secondary to microtrauma and instability were identified. Her symptoms were managed conservatively with activity modification and physical rehabilitation. Complete resolution of symptoms was reported by a six-month follow-up, and no further dislocations or instability had been reported at 12 months.HA is a low-risk, minimally invasive procedure with numerous indications, including acetabular labral tears, FAI, chondral lesions, osteochondritis dissecans, ligamentum teres injuries, snapping hip syndrome, iliopsoas bursitis, and loose bodies . Hip artWith such an exceedingly low complication rate, post arthroscopic hip dislocation has not been well documented. The majority of cases of hip dislocation after HA reported have been anterior hip dislocations -13. AlteOur patient underwent a transverse limb capsulotomy of the anterior joint capsule without repair, rim trimming of the acetabular margin, and femoroplasty with cam lesion resection. Interestingly, our patient experienced anterior hip dislocation only five days post arthroscopy. The patient also sustained a femoral head fracture, intra-articular loose bodies, and focal cartilage loss that resulted from the original injury. We can postulate from our experience that intraoperative distension and stretching of the anterior joint capsule may create instability and thus the risk for dislocation and subsequent injuries. Prior studies reported dislocation events that occurred immediately in the recovery room , on postInciting mechanisms vary depending on the activity level of the individual. Less active individuals frequently report a low energy twist or fall ,10,11. AOur patient was diagnosed with new-onset iliopsoas bursitis eight weeks following closed reduction of her post arthroscopic anterior hip dislocation. Six other cases describe further complications that required additional surgery: residual pain and apprehension treated with arthroscopic capsular plication , gross hAnterior hip dislocation after HA is an uncommon postoperative complication of an otherwise safe and well-regarded procedure. Surgeons must be aware of the surgical and patient-specific risk factors that contribute to postoperative hip instability in order to optimize patient safety in both the acute and chronic stages of recovery. Furthermore, the presence of iliopsoas bursitis, degenerative arthritis, and other causes of continued hip pain following closed hip reduction is an important topic that requires further investigation as the incidence of these complications is likely to rise with a growing number of hip arthroscopy procedures. This case emphasizes the need to investigate safer techniques to minimize postoperative complications, avoid dislocation after hip arthroscopy, and successfully manage resulting pathology.


Implementing intergenerational programming amidst the COVID-19 pandemic has required creativity, partnership, and dedication to the work. Most intergenerational programs involving in-person meetings or events are accompanied by guidelines to protect participant health and safety. Programming is routinely cancelled or postponed due to poor weather or contagious illness, particularly when a vulnerable population is involved. The needs for safety precautions and continued intergenerational contact were both amplified during the pandemic, leading many to modify or innovate ways to engage generations rather than eliminate contact for extended periods. Technology has afforded new approaches to engage young people and older people with each other; non-technological ways have also proven effective. This symposium will address strategies used to implement intergenerational programs during the pandemic. Authors will highlight lessons learned and strategies they expect to retain in the future. The first paper describes a pivot in nutrition programming designed for a shared site with preschool children and frail older adults. In paper two, authors discuss their partnership-based approach shifting to remote offerings of Cyber-Seniors programming. Paper three addresses how MentorUp Service-Learning expanded its reach by adaptations to virtual programming for older adults in retirement communities. The final paper presents evaluation data comparing arts programming delivered in-person pre-pandemic and again virtually during the pandemic. In each case, researchers and community partners learned techniques to maintain their programmatic foci. Some projects developed strategies they plan to maintain post-pandemic. Donna Butts, Executive Director of Generations United serves as the symposium discussant.


This session examines innovative approaches to effectively address the aging services workforce needs in rural, Midwestern settings. Presenters will explore career pathways and transfer opportunities in gerontology education, as well as best practices for addressing the educational, professional and personal needs of diverse student populations.


Objectives are to detail the model, pilot funding mechanism, early research findings and infrastructure investments. METHODS/STUDY POPULATION: The health research system has widely acknowledged challenges that can delay research translation to systems that advance health for chronically disadvantaged health disparity population groups. MSM’s vision is to lead the creation and advancement of health equity. The vision-aligned strategic plan prioritized formalization of a TX TM implementation priority. The study population was the institution’s research faculty and leaders, research administration, and communication arm. Through a cross-institutional working group, a plan was deployed to 1) assess the institutional landscape, 2) review the grey and peer reviewed literature on translational research and 3) invest in a pilot research funding mechanism. RESULTS/ANTICIPATED RESULTS: Over $700K has been invested in TX TM implementation. Over half of research faculty completed an institutional landscape assessment to identify translational research expertise, interests and points of interest in new collaboration. The most frequently cited collaborative research interests were clinical research with human subjects, patient-centered outcomes and laboratory-based research with human subjects/specimens. Funded multidisciplinary and/or community-engaged pilot studies investigate the role for circadian rhythms and shift work, cultural variables influencing mental health among Haitians living in the US and integrating prescription reconciliation telehealth in primary care. DISCUSSION/SIGNIFICANCE OF IMPACT: TX TM requires interdisciplinary collaboration across translational research spheres and beyond the academy. Institutional investment, infrastructure support and senior-level champions are central to awareness and rewarding such scholarship towards scaling approaches that advance health equity. CONFLICT OF INTEREST DESCRIPTION: Coined at Morehouse School of Medicine (MSM), Tx TM symbolizes an approach and scientific philosophy designed to intentionally promote and support convergence of interdisciplinary approaches and scientists to stimulate exponential advances for the health of diverse communities.OBJECTIVES/GOALS: Morehouse School of Medicine (MSM), T


Inpatient falls are a persistent problem and despite research efforts during the last decade, inpatient fall rates have not significantly decreased. Older adults have an estimated 50% greater inpatient fall rate than younger adults. How older adults perceive their own fall risk affects their adherence to fall prevention recommendations. The aim of this phenomenological study was to gain a deeper understanding of the lived experiences of being at risk for falling in the hospital among older adults aged 65 years and older (N=9). Participants  were interviewed twice using video conferencing within two weeks of hospital discharge. The audio-recorded interviews were transcribed, and then analyzed using van Manen’s interpretive phenomenological method. The Health Belief Model expanded with the concepts of independence, fear of falling, embarrassment, dignity, and positivity effect served as the theoretical framework. Five major interpretive themes emerged: Relying on Myself, Managing Balance Problems in an Unfamiliar Environment, Struggling to Maintain Identity, Following the Hospital Rules, and Maintaining Dignity in the Relationships with Nursing Staff. These themes describe how the participants thoughtfully planned their mobilization to avoid falls. This process was influenced by their struggling to remain independent, following the hospital fall prevention rules out of politeness, and experiencing both positive and negative relationships with nursing staff. Hospitalized older adults employed their self-efficacy to manage balance problems in the hospital. These findings have not been previously documented in the literature. Fall prevention interventions supporting hospitalized older adults’ self-management of fall risk are needed.


The 2019 Global Assessment Report (GAR2019) on Disaster Risk Reduction , the ideThe current special issue primarily focuses on how cascading disaster risk can be analyzed and modeled—to support decision-making about disaster mitigation, preparation, and response. The special issue covers cascading impacts triggered by multiple hazard types, cascading impacts triggered by extreme rainfall events and by ground deformation, and the cascading impacts of business and infrastructure disruptions. Specific issues concerning the risk of cascading hazards for oil storage infrastructure and for underground railways are also analyzed, alongside potential mitigation measures. Other papers outline the importance of organization within social networks and of public health provision for cascading disaster management.Mignan and Wang  analyzedHuggins et al.  focused Cando-Jácome et al.  used an Dubaniowski and Heinimann  used an Zhang et al.  developeWang et al.  analyzedChen et al.  focused Harada et al.  providedThe current special issue on Cascading Disaster Modelling and Prevention includes several examples of how cascading disaster analysis supports a more preventative and pro-active approach to cascading disaster risk. Case study reviews and other data analyses have illustrated how cascading impacts are triggered by multiple hazard types, and can be characterized by severe infrastructural and organizational disruptions. Relevant analyses have been conducted for specific sites, namely oil depots and underground railway systems. In both cases, innovative approaches to analytical modeling have identified key targets for cascading hazard mitigation. The remaining pair of special issue papers highlight the potential to learn from prior disasters, which have already affected large populations and broad geographical areas. Flexible and well-networked capacities remain paramount, especially where mitigation has not been achieved or where key targets for mitigation have not yet been identified. Analytical efforts are ongoing to help ensure that larger scale cascading disaster management can leverage more of the analytical precision that characterizes site-specific analyses.


Theoretical and empirical evidence suggests the existence of a general perceived stress factor overarching different life domains. The present study investigated the general perceived stress relative to domain-specific perceived stress as predictors of 26 diverse health outcomes, including mental and physical health, health behaviors, cognitive functioning, and physiological health indicators. A bifactor exploratory structural equational modelling approach was conducted in two samples from the Health and Retirement Study. Across the two samples, perceived stress was well-represented by a bifactor structure where there was a robust general perceived stress factor representing a general propensity towards stress perception. Meanwhile, after controlling for the general factor, specific factors representing perceived stress in different life domains were still clearly present. The general perceived stress factor was the most robust predictor of the majority of health outcomes. Age, sex, personality traits, and stressor exposure were found as possible diathesis underlying the general perceived stress factor.


Peak intra-articular load distribution for active squatting was lateral-heavy, contrasting to the medial-heavy distribution observed in passive intraoperative measurements, for all specimens. These aspects should be given due consideration while assessing intraoperative and postoperative joint stability following TKA.Ligament balancing during total knee arthroplasty (TKA) often relies on subjective surgeon experience. Although instrumented tibial trays facilitate an objective assessment of intraoperative joint balance through quantification of intra-articular joint loads, postoperative clinical assessment of joint balance relies on passive stress tests quantifying varus–valgus joint laxity. This study aimed at correlating the intraoperative and postoperative metrics used to assess joint balance while also comparing joint loads obtained during passive assessment and active functional motions. Four experienced surgical fellows were assigned a fresh-frozen lower limb each to plan and perform posterior-stabilised TKA. An instrumented tibial insert measured intraoperative intra-articular loads. Specimens were then subjected to passive flexion–extension, open-chain extension, active squatting, and varus–valgus laxity tests on a validated knee simulator. Intra-articular loads were recorded using the instrumented insert and tibiofemoral kinematics using an optical motion capture system. A negative correlation was observed between mean intraoperative intra-articular loads and corresponding mean postoperative tibial abduction angle during laxity tests (medial: R = −0.93,  Total knee arthroplasty (TKA) is an established surgical procedure to treat severe osteoarthritis in the knee; however, joint instability has been reported as a major cause of postoperative patient dissatisfaction . Soft-tiVerasense , a smart tibial tray compatible with already existing TKA designs, facilitates the quantitative measurement of soft-tissue balancing during TKA by measuring intraoperative loads in situ in the medial and lateral compartments at the points of contact between the femoral condyles and tibial plateaux ,7. With While intra-articular loads are used to achieve joint stability intraoperatively, clinical assessment of postoperative joint stability typically relies on passive tests, such as the stress tests quantifying the varus–valgus laxity of the knee at multiple flexion angles , performMoreover, while this manual passive postoperative assessment of joint stability is performed at constant flexion angles, the aim is to have desired postoperative joint stability for dynamic activities of daily living, such as walking, over the entire range of knee flexion. Active motions differ from their passive counterparts primarily owing to active muscle force production, as well as their often closed-chain nature resulting in higher joint contact forces .Therefore, the primary aim of this in vitro study was to correlate intraoperative intra-articular loads to the postoperative tibiofemoral abduction measured during the varus–valgus stress tests, hypothesizing a negative correlation between the two parameters. The secondary aim of this study was to compare intra-articular loads measured intraoperatively to those measured postoperatively during passive and active motions, with the hypothesis that active motions would alter load distribution between the medial and lateral compartments owing to a change in joint dynamics and muscle force production.Four fresh-frozen cadaveric specimens  were obtained from the institute body donation programme following ethical approval by the local ethics committee. None of the specimens had signs of lower limb disorder or prior surgical intervention.Magnetic resonance imaging and full leg radiographs were obtained for each specimen to design specimen-specific cutting blocks for the TKA surgery using the VISIONAIRE protocol . Rigid marker frames with reflective spheres (diameter = 12 mm) were attached to the femur and tibia using bicortical bone pins. Computed-tomography (CT) scans  obtained for each frozen specimen in full extension were used to identify the location of the markers relative to anatomic landmarks  in order to define a joint coordinate system for the femur and tibia .Each lower limb was thawed for 24 h before resecting it 32 cm proximally and 28 cm distally to the knee joint. Care was taken to preserve the joint capsule, ligaments, and tendons while dissecting the surrounding skin and subcutaneous tissue. The femur and tibia were embedded in metal pots using acrylic resin  in a physiologic orientation. Tendons of the quadriceps and the hamstrings were carefully exposed and prepared to be attached to an electromechanical actuator for dynamic control and passive springs for constant tensile load application, respectively.Each of the four specimens was randomly allotted to one of four experienced surgical fellows  scores > 85%) ,12. SurgFollowing implantation, each specimen was mounted on a previously validated physiological knee-joint simulator  and subjThe specimen was kept moist during experimental testing with phosphate-buffered saline solution to mitigate tissue-drying effects. The order of tasks performed was randomized to avoid potential bias. Each task was performed in triplicate by a single operator.A six-camera motion capture system  was used to track the motion of the femur and tibia. Intra-articular loads in the medial and lateral compartments of the knee were recorded during all tasks using the custom company software .p < 0.05). Peak intra-articular loads in the medial and lateral compartments were calculated for passive flexion–extension, open-chain extension, and active squatting, and compared to values obtained intraoperatively.The recorded trajectories of markers on the femur and tibia were processed further  to calculate tibiofemoral kinematics for each specimen using a custom code  based on joint coordinate systems defined using anatomical landmarks obtained from CT. The relationship between postoperative joint laxity, measured using the tibial abduction angle during varus–valgus stress tests, and intraoperative intra-articular load was assessed for each specimen using the Pearson correlation test   than in flexion (4.4 ± 2.4°) postoperatively . Mean po = 0.04) .Peak total intra-articular load across the range of knee flexion was higher for actively loaded tasks—open-chain extension and squatting—as compared to passive measurements, with the peak load during squatting being the highest amongst all tasks for three out of the four specimens . For allIn the case of peak loads for intraoperative measurements, passive flexion–extension, and open-chain extension, loads in the medial compartment were higher than those in the lateral compartment for three out of the four specimens; however, for active squatting, loads in the lateral compartment were higher than those in the medial compartment for all specimens .Ligament balancing is vital in the successful outcome of TKA ; howeverOne of the highlights of this study was the participation of four experienced surgical fellows, each performing specimen-specific TKA. The same implant was used by all fellows to avoid implant-specific variability in postoperative biomechanics; however, specimen-specific cutting guides were based on the preoperative surgical planning performed by each fellow. Moreover, although trained at different institutions globally, the fellows followed standard surgical norms of joint balancing during TKA ,3. This Intra-articular loads measured during TKA revealed that all specimens were tighter in extension, thereby leading to higher loads, than in flexion . MoreovePostoperative joint laxity largely corroborated with intraoperative intra-articular loads, since it was ensured that implant sizes and/or component alignments were not altered following intraoperative joint balancing assessment with the instrumented tibial trays. Postoperative tibial adduction and abduction during the varus and valgus stress tests, respectively, were higher in flexion than in extension , therebyPeak total intra-articular load over the range of knee flexion was higher for dynamic loaded tasks as compared to static measurements , with thHowever, this was not the case for one specimen (Spec 2), which exhibited such high intra-articular loads during intraoperative measurements already that the differences in peak loads between passive and active motions were minimal, as compared to those observed in other specimens . MoreoveAlthough this unique cadaveric simulator study included state-of-the-art instrumented sensors, one of the main shortcomings of the study was the small sample size. Future studies should not only look to include a larger number of specimens but also increase the number of static flexion angles used to test intraoperative intra-articular loads and corresponding postoperative joint laxity, thereby facilitating a better correlation analysis of the two parameters with statistical and clinical significance. Another limitation was the underlying assumption that Verasense sensors could sustain intra-articular pressure encountered during the actively loaded squatting motion, often reaching ~16 MPa , withoutA conformance between intraoperative intra-articular joint loads and postoperative joint laxity was observed, although the correlation between these parameters was not statistically significant for all specimens. Moreover, there was a stark discrepancy in peak joint load distribution across the medial and lateral compartments between passive tasks and active functional motions. These aspects should be given due consideration while performing a joint balancing procedure during TKA, as well as clinically assessing postoperative joint stability.


Entrapment peripheral neuropathies are clinically characterized by sensory impairment and motor deficits. They are usually caused by mechanical injuries, but they are also a frequent manifestation of metabolic diseases, toxic agent exposure, or systemic fibrotic disorders. Here we describe the clinical, radiological, and histopathological features of a novel progressive fibrotic disorder characterized by progressive multifocal fibrosing neuropathy. We identified two patients who presented with severe and progressive peripheral neuropathic symptoms sequentially affecting multiple sites. These patients presented with severe and progressive multifocal, sequentially additive peripheral neuropathic symptoms. Extensive nerve conduction and radiological studies showed the sequential development of multifocal motor and sensory peripheral neuropathy in the absence of any exposure to known infectious, inflammatory, or fibrotic triggers and the lack of family history of compression neuropathies. Extensive clinical and laboratory test evaluation failed to support the diagnosis of any primary inflammatory or genetic peripheral neuropathy and there was no evidence of any systemic fibrosing disorder including Systemic Sclerosis, lacking cutaneous fibrotic changes and cardiopulmonary abnormalities. The clinical course was progressive with sequential development of motor and sensory deficits of upper and lower extremities displaying proximal predominance. Histopathological study of tissues obtained during nerve release surgeries showed severe perineural fibrosis with marked accumulation of thick collagen bundles encroaching the peripheral nerves. There was no evidence of vasculitic, inflammatory, or vascular fibroproliferative lesions. We suggest that the clinical findings described here represent a previously undescribed fibrotic disorder affecting peripheral nerves, and we propose the descriptive term "Progressive Multifocal Fibrosing Neuropathy" to refer to this novel disorder. Despite the inherent limitations of this early description, we hope this is would contribute to the identification of additional cases. Peripheral neuropathies caused by nerve compression or entrapment syndromes manifest clinically by sensory impairment and motor deficits. They most commonly result from chronic mechanical injuries of nerve tracts in fibro-osseous canals or compression by other tissue structures, including tendons, ligaments, and muscles , 2. SlowHere, we describe two patients who developed a novel disorder characterized by severe and progressive peripheral neuropathy with multifocal and sequential involvement of multiple sites. Extensive neurological and histopathological studies demonstrated that this process was caused by encroachment of nerve tracts by the accumulation of large amounts of excessive fibrotic tissue in the absence of genetic or acquired neurological disorders or systemic inflammatory or fibrotic diseases. Therefore, it is suggested that this clinical entity represents a previously undescribed fibrotic disorder affecting the peripheral nerves.Both patients were referred to the Scleroderma Center at Thomas Jefferson University for evaluation of a systemic fibrosing disorder causing progressive neuropathy affecting multiple peripheral nerves. Appropriate laboratory tests for the assessment of SSc and SSc-like disorders, including autoantibody testing, nail-fold video-capillaroscopy, pulmonary function tests, high-resolution chest computed tomography, and echocardiograms were performed. Neurological evaluations, including extensive clinical and electrophysiological assessment, were performed by a neuromuscular neurologist (M.C.D); and radiological studies included resonance imaging (MRI), and ultrasonography. Histopathological studies of biopsies from affected nerves and surrounding tissue obtained during decompression surgeries were performed. The tissues were stained with hematoxylin–eosin (H&E), and Masson’s Trichrome stains, immunohistochemistry studies for inflammatory cell markers including CD3, CD8, CD20, and CD68 were performed. A search for peripheral myelin protein (PMP22) gene mutations to exclude hereditary neuropathy with liability to pressure palsies (HNPP) was performed in both patients .A 37-year-old female presented with three months history of severe pain localized to the left genital area. An initial evaluation was negative for infectious etiologies. Owing to the persistence of symptoms, an MRI was performed. The study disclosed soft-tissue edema surrounding the left pudendal nerve , silica, organic solvents, pesticides, radiation, occupation/hobby exposures, or other identifiable environmental factors. No family history of a similar syndrome was found. Laboratory testing in both cases showed the absence of eosinophilia and tests for antinuclear antibody were negative. Repeated analysis failed to show elevation of inflammatory markers (ESR and CRP). Genetic testing did not disclose any peripheral myelin protein 22 (PMP22) mutations. An echocardiogram did not show signs of pulmonary hypertension or myocarditis, and pulmonary function tests (PFTs) were normal. There was no clinical or laboratory evidence to suggest the diagnosis of diabetes mellitus.Given the fact that the findings of EMG/NC studies correlated with the clinical picture in both patients and provided imaging evidence of entrapment neuropathy, lumbar puncture and CSF analysis were not performed.MRI of the pelvic area showed marked perineural edema surrounding the left pudendal nerve of patient 1 and right pudendal nerve in patient 2  , 18, an Given the fact that several systemic fibro-inflammatory conditions have been related to an exogenous triggering agent, an extensive and detailed inquiry was performed but failed to disclose any toxic exposure. Although patients with more than one neuropathic compressive syndrome affecting the same extremity, usually associated with thoracic outlet syndrome have been described and a “double crush mechanism” was proposed for those cases , 22, in An extensive review of the published medical literature indicates that there was no previously described syndrome or disease with the clinical and histopathological findings described in this report and the cases and the cases studied and reported appear to be unique. Therefore, it is suggested that this may represent a novel clinical entity descriptively termed "Multifocal Progressive Fibrosing Neuropathy". The most important features distinguishing Multifocal Progressive Fibrosing Neuropathy from SSc, TOS, EF, EMS, and NSF, and other neurological diseases frequently causing neuropathy are listed in Tables Finally, we can hypothesize that owing the absence of inflammation in immunopathological studies but significant fibrosis, these patients could benefit from the use of antifibrotic drugs.