Despite the high prevalence of underage drinking, little is known about alcohol withdrawal syndrome (AWS) in adolescents and young adults. The aim of this study is to characterize AWS in this population. We conducted a retrospective chart review of all hospital admissions with the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) protocol at Mayo Clinic between June 2019 and June 2022. We identified a total of 10,220 patients with 16,338 hospital admissions where CIWA-Ar protocol was implemented. Within this cohort, 130 patients (70 male and 60 female; 1.3% of all patients) with 148 admissions (0.9% of all admissions) were under 21 years of age. A total of 44% of patients (n = 65) presented with suicidal ideations, and 26% (n = 40) had suicide attempts. In all, 22 (n = 33) required admission to the intensive care unit. The median length of stay in the intensive care unit was 32.8 hours. The median peak CIWA-Ar score was 9 (minimum-maximum = 4-39, interquartile range = 7), and the median time from hospital admission to peak CIWA-Ar score was 9.4 hours (minimum-maximum = 0.1-126, interquartile range = 20.2). A total of 40% of patients (n = 59) received benzodiazepines, whereas 20% (n = 31) required antipsychotics. Three patients (2%) developed delirium tremens, and 5 episodes of alcohol withdrawal seizures (3.4%) were observed. No deaths were reported during hospitalization. However, over the subsequent follow-up period from 2019 to 2023, the all-cause post-hospitalization mortality rate was 3% (n = 4) within 1.6 (±0.6) years. These data suggest that adolescents and young adults presenting for treatment of AWS are at risk for morbidity and mortality due to suicidality and withdrawal complications such as withdrawal seizures and delirium tremens. Further studies should evaluate the underlying social and neurobiological predictors of vulnerability and resilience in this age group.

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

Background: Immediate lymphatic reconstruction (ILR) via lymphovenous anastomosis is performed in patients undergoing axillary lymph node dissection (ALND) to minimize the risk of lymphedema. Following ALND, drains are placed to prevent seromas, while prolonged drain days are associated with increased risk of infection. The study aim was to determine the impact of ILR on the number of drain days following ALND in patients with breast cancer. Methods: We report a post-hoc analysis of a prospective trial (April 2018-January 2023) comparing patients with breast cancer who underwent ALND with ILR (intervention arm) vs ALND without ILR (control arm). Wilcoxon rank sum test and chi-squared or Fisher’s exact tests compared continuous and categorical variables, respectively. Multivariable quantile regression models evaluated the difference in drain days and days until drain removal criteria were met with covariates adjusted. Results: Data from 214 patients were analyzed (n = 115 interventional arm, n = 99 control arm). The intervention arm had a median of 15 axillary drain days compared to 11 days in the control arm ( P = .001). There was no significant difference between groups when measuring drain days based on the date the drain met removal criteria, rather than actual drain removal date. Seroma incidence was lower in the intervention arm (3.5%) vs the control arm (12.1%) ( P = .017) without a statistical difference in incidence of infection. Conclusion: ALND with ILR does not decrease the number of drain days compared to ALND without ILR in patients with breast cancer, although we found the incidence of seromas to be lower without increase in incidence of infection.

Background/Objectives: To evaluate the association between orthopaedic consultation and Emergency Department (ED) length of stay among patients with clavicle, radial head, and proximal humerus fractures meeting criteria for nonacute management (discharge without orthopaedic consultation). Methods: All adult patients presenting to a single Level 1 trauma centre between 2019 and 2022 with a clavicle, radial head, or proximal humerus fracture that met criteria for nonacute management (discharge without orthopaedic consultation) were identified from an institutional database. Post-imaging ED length of stay, defined as time from radiograph completion to discharge or admission, was compared between patients discharged per protocol without orthopaedic consultation and those discharged after receiving orthopaedic consultation. A mixed-effects linear log regression model with orthopaedic surgery consult, age and sex as fixed effects and year of presentation as a random intercept was used to model the effect of not having an orthopaedic surgery consult on length of stay. A post hoc sensitivity analysis excluding patients who were admitted was performed. Results of the regression model are presented with corresponding 95% confidence intervals. Results: This study included 523 patients (average age 57 years, 58% female) with 115 clavicle, 269 proximal humerus, and 139 radial head fractures. Among patients meeting criteria for nonacute management, those who were discharged per protocol without orthopaedic consultation had a 59%, 56%, and 55% reduction in length of stay for clavicle, radial head, and proximal humerus fractures, respectively (all p < 0.001). Only 3/523 (0.6%) were admitted to orthopaedic surgery. Results were consistent in post hoc sensitivity analysis. Conclusions: Discharge without orthopaedic consultation among patients with clavicle, radial head, or proximal humerus fractures meeting criteria for nonacute management was associated with substantially shorter ED length of stay. Adherence to this protocol may aid in reducing overcrowding in the ED.

Introduction: Although primarily supplied by the vertebrobasilar system, the hippocampus is partially supplied by ipsilateral carotid artery branches through the anterior choroidal artery or a prominent posterior communicating artery. We report a patient with acute hippocampus infarction likely due to symptomatic ipsilateral tandem carotid stenosis and discuss acute vascular-mediated hippocampal injury. Case Report: An 80-year-old female with obesity, dyslipidemia, hypertension, alcohol use disorder, history of breast cancer on letrozole, and traumatic brain injury was brought into our emergency department for 24 hours of confusion. On examination, she exhibited limited registration, recall, and executive dysfunction with otherwise normal language, visuo-spatial orientation, and praxis. Brain MRI showed a small area of diffusion restriction in the anterior right hippocampus with matched FLAIR hyperintensity, consistent with acute infarction. Computed tomography angiogram head and neck showed 90% stenosis of the proximal right internal carotid artery (ICA), <50% narrowing of the proximal left ICA, and moderate bilateral narrowing of the paraclinoid ICAs, all due to calcific atheromatous plaques. The etiology of the hippocampal infarction was suspected embolism from the ipsilateral severe carotid stenosis. Planning for right cervical carotid revascularization ensued. Conclusion: This case highlights the dual hippocampal vascular supply and that hippocampal embolic infarcts could be a sign of a symptomatic severe carotid artery stenosis that may require urgent revascularization for stroke secondary prevention.