Delayed Ventricular Septal Rupture Repair on Patient Outcomes After Myocardial Infarction: A Systematic Review.

Even though the prevalence of VSR after MI is only 1%-3%, the mortality associated with the condition is more than 80%. Very few studies in the literature have described in detail the treatment options for delayed VSR repair. This systematic review was conducted to evaluate the outcomes of delayed ventricular septal rupture (VSR) repair following acute myocardial infarction (AMI). Digital databases were searched systematically to identify studies reporting the outcomes of delayed VSR repair. Detailed study and patient-level baseline characteristics including the type of study, sample size, follow-up, number of delayed repairs, time to repair, outcomes (in terms of major adverse cardiovascular events), and predictors of outcome were abstracted. A total of 12 studies, recruiting 8,579 patients were included in the final analysis. Male gender, young age (<60 years), and delayed VSR repair were reported as predictors of survival along with left ventricular assist devices (LVADs) and extracorporeal membrane oxygenation (ECMO), and the use of inotropes before surgery. Postoperative renal failure, higher New York Heart Association (NYHA) score, early repair, and history of heart failure (HF) were demonstrated as predictors of mortality. This study demonstrated that delayed VSR repair can reduce mortality in patients who develop VSR after AMI. Furthermore, the use of LVADs can prolong the time of surgery, and the use of inotropes can predict survival benefits in this patient cohort.

Treatment selection towards active surveillance over definitive treatment for pituitary adenomas is influenced by sociodemographic factors.

BACKGROUND: Clinical and sociodemographic predictors of pituitary adenoma (PA) patients undergoing active surveillance (AS) versus definitive treatment (DT) are poorly understood. OBJECTIVE: This population-based analysis aims to identify clinical and sociodemographic predictors of undergoing AS versus DT. METHODS: The National Cancer Database (NCDB) was utilized to query PA patients diagnosed from 2010 to 2015 undergoing AS or DT. Independent-samples t-test and chi-squared test were used to compare differences in patient baseline characteristics and a stepwise binary logistic regression was performed to elucidate factors implicated in undergoing AS. RESULTS: The cohort consisted of 30,233 PA patients, with 5147 (17.0%) patients undergoing AS. On multivariable logistic regression, patients aged ≥ 65 years (OR=1.65; p < 0.001), African American race (OR=1.12; p = 0.035), having government insurance (OR=1.45; p < 0.001) or those uninsured (OR=1.58; p < 0.001) were significantly more likely to undergo AS compared to DT, while patients with larger tumors (OR=0.90; p < 0.001), receiving treatment at academic facilities (OR=0.75; p < 0.001), and living in West regions of the United States (OR=0.59; p < 0.001) were significantly less likely to undergo AS compared to DT. CONCLUSIONS: Significant sociodemographic disparities exist in patient selection for undergoing AS versus DT, which may modify patient clinical outcomes.

Development of a novel frameless skull-mounted ball-joint guide array for use in image-guided neurosurgery.

OBJECTIVE: Successful convection-enhanced delivery of therapeutic agents to subcortical brain structures requires accurate cannula placement. Stereotactic guiding devices have been developed to accurately target brain nuclei. However, technologies remain limited by a lack of MRI compatibility, or by devices' size, making them suboptimal for direct gene delivery to brain parenchyma. The goal of this study was to validate the accuracy of a novel frameless skull-mounted ball-joint guide array (BJGA) in targeting the nonhuman primate (NHP) brain. METHODS: Fifteen MRI-guided cannula insertions were performed on 9 NHPs, each targeting the putamen. Optimal trajectories were planned on a standard MRI console using 3D multiplanar baseline images. After cannula insertion, the intended trajectory was compared to the final trajectory to assess deviation (euclidean error) of the cannula tip. RESULTS: The average cannula tip deviation was 1.18 ± 0.60 mm (mean ± SD) as measured by 2 independent reviewers. Topological analysis showed a superior, posterior, and rightward directional bias, and the intra- and interclass correlation coefficients were > 0.85, indicating valid and reliable intra- and interobserver evaluation. CONCLUSIONS: The data demonstrate that the BJGA can be used to reliably target subcortical brain structures by using MRI guidance, with accuracy comparable to current frameless stereotactic systems. The size and versatility of the BJGA, combined with a streamlined workflow, allows for its potential applicability to a variety of intracranial neurosurgical procedures, and for greater flexibility in executing MRI-guided experiments within the NHP brain.

Interfacing with the nervous system: a review of current bioelectric technologies.

The aim of this study is to discuss the state of the art with regard to established or promising bioelectric therapies meant to alter or control neurologic function. We present recent reports on bioelectric technologies that interface with the nervous system at three potential sites-(1) the end organ, (2) the peripheral nervous system, and (3) the central nervous system-while exploring practical and clinical considerations. A literature search was executed on PubMed, IEEE, and Web of Science databases. A review of the current literature was conducted to examine functional and histomorphological effects of neuroprosthetic interfaces with a focus on end-organ, peripheral, and central nervous system interfaces. Innovations in bioelectric technologies are providing increasing selectivity in stimulating distinct nerve fiber populations in order to activate discrete muscles. Significant advances in electrode array design focus on increasing selectivity, stability, and functionality of implantable neuroprosthetics. The application of neuroprosthetics to paretic nerves or even directly stimulating or recording from the central nervous system holds great potential in advancing the field of nerve and tissue bioelectric engineering and contributing to clinical care. Although current physiotherapeutic and surgical treatments seek to restore function, structure, or comfort, they bear significant limitations in enabling cosmetic or functional recovery. Instead, the introduction of bioelectric technology may play a role in the restoration of function in patients with neurologic deficits.

Extensive Transduction and Enhanced Spread of a Modified AAV2 Capsid in the Non-human Primate CNS.

The present study was designed to characterize transduction of non-human primate brain and spinal cord with a modified adeno-associated virus serotype 2, incapable of binding to the heparan sulfate proteoglycan receptor, referred to as AAV2-HBKO. AAV2-HBKO was infused into the thalamus, intracerebroventricularly or via a combination of both intracerebroventricular and thalamic delivery. Thalamic injection of this modified vector encoding GFP resulted in widespread CNS transduction that included neurons in deep cortical layers, deep cerebellar nuclei, several subcortical regions, and motor neuron transduction in the spinal cord indicative of robust bidirectional axonal transport. Intracerebroventricular delivery similarly resulted in widespread cortical transduction, with one striking distinction that oligodendrocytes within superficial layers of the cortex were the primary cell type transduced. Robust motor neuron transduction was also observed in all levels of the spinal cord. The combination of thalamic and intracerebroventricular delivery resulted in transduction of oligodendrocytes in superficial cortical layers and neurons in deeper cortical layers. Several subcortical regions were also transduced. Our data demonstrate that AAV2-HBKO is a powerful vector for the potential treatment of a wide number of neurological disorders, and highlight that delivery route can significantly impact cellular tropism and pattern of CNS transduction.

Plasma metabolomic biomarkers accurately classify acute mild traumatic brain injury from controls.

Past and recent attempts at devising objective biomarkers for traumatic brain injury (TBI) in both blood and cerebrospinal fluid have focused on abundance measures of time-dependent proteins. Similar independent determinants would be most welcome in diagnosing the most common form of TBI, mild TBI (mTBI), which remains difficult to define and confirm based solely on clinical criteria. There are currently no consensus diagnostic measures that objectively define individuals as having sustained an acute mTBI. Plasma metabolomic analyses have recently evolved to offer an alternative to proteomic analyses, offering an orthogonal diagnostic measure to what is currently available. The purpose of this study was to determine whether a developed set of metabolomic biomarkers is able to objectively classify college athletes sustaining mTBI from non-injured teammates, within 6 hours of trauma and whether such a biomarker panel could be effectively applied to an independent cohort of TBI and control subjects. A 6-metabolite panel was developed from biomarkers that had their identities confirmed using tandem mass spectrometry (MS/MS) in our Athlete cohort. These biomarkers were defined at ≤6 hours following mTBI and objectively classified mTBI athletes from teammate controls, and provided similar classification of these groups at the 2, 3, and 7 days post-mTBI. The same 6-metabolite panel, when applied to a separate, independent cohort provided statistically similar results despite major differences between the two cohorts. Our confirmed plasma biomarker panel objectively classifies acute mTBI cases from controls within 6 hours of injury in our two independent cohorts. While encouraged by our initial results, we expect future studies to expand on these initial observations.

A historical recount of chordoma.

Chordoma, a rare bone tumor that occurs along the spine, has led scientists on a fascinating journey of discoveries. In this historical vignette, the authors track these discoveries in diagnosis and treatment, noting events and clinicians that played pivotal roles in our current understanding of chordoma. The study of chordoma begins in 1846 when Rudolf Virchow first observed its occurrence on a dorsum sellae; he coined the term "chordomata" 11 years later. The chordoma's origin was greatly disputed by members of the scientific community. Eventually, Müller's notochord hypothesis was accepted 36 years after its proposal. Chordomas were considered benign and slow growing until the early 1900s, when reported autopsy cases drew attention to their possible malignant nature. Between 1864 and 1919, the first-ever symptomatic descriptions of various forms of chordoma were reported, with the subsequent characterization of chordoma histology and the establishment of classification criteria shortly thereafter. The authors discuss the critical historical steps in diagnosis and treatment, as well as pioneering operations and treatment modalities, noting the physicians and cases responsible for advancing our understanding of chordoma.

The effect of resveratrol on expression of matrix metalloproteinase 9 and its tissue inhibitors in vascular smooth muscle cells.

BACKGROUND: Matrix metalloproteinase 9 (MMP-9) is involved in extracellular matrix degradation and remodeling. An increase in MMP-9 expression by vascular component cells plays an important role in atherosclerotic plaque formation and rupture. Resveratrol, a polyphenolic substance, was suggested to play a role in preventing the progress of atherosclerotic disease. The aim of this study was to investigate the effect of resveratrol on MMP-9 and tissue inhibitors of metalloproteinases (TIMPs) in vascular smooth muscle cells (VSMCs) after treatment with H2O2. METHODS: Cultured VSMCs were pre-treated with 0.2 mM of H2O2 before stimulation with different concentration of resveratrol. Expression of MMP-9, TIMP-1, and TIMP-3 genes were measured using real-time polymerase chain reaction (PCR) method, and MMP-9 protein level was detected using western blot analysis. RESULTS: Resveratrol at 120 µmol/l concentration reduced the elevated level of MMP-9 induced by H2O2 in VSMCs as 1.85 ± 0.35 folds (P < 0.050) and 8.70 ± 1.20 folds (P < 0.050) after 24 and 48 hours, respectively. Resveratrol increased the diminished level of TIMP-1 induced by H2O2 as 2.5 ± 0.48 folds following the treatment with 120 µmol/l after 48 hours (P < 0.050). CONCLUSION: Resveratrol as an antioxidant can decrease MMP-9 production, not only by suppressing MMP-9 expression, but also by augmenting TIMP-1 production. Altogether, resveratrol as an antioxidant can regulate the MMP-9/TIMP-1 balance, and may be considered as a preservative agent in the treatment and prevention of atherosclerosis.

Functional and Histological Effects of Chronic Neural Electrode Implantation.

OBJECTIVES: Permanent injury to the cranial nerves can often result in a substantial reduction in quality of life. Novel and innovative interventions can help restore form and function in nerve paralysis, with bioelectric interfaces among the more promising of these approaches. The foreign body response is an important consideration for any bioelectric device as it influences the function and effectiveness of the implant. The purpose of this review is to describe tissue and functional effects of chronic neural implantation among the different categories of neural implants and highlight advances in peripheral and cranial nerve stimulation. Data Sources: PubMed, IEEE, and Web of Science literature search. Review Methods: A review of the current literature was conducted to examine functional and histologic effects of bioelectric interfaces for neural implants. RESULTS: Bioelectric devices can be characterized as intraneural, epineural, perineural, intranuclear, or cortical depending on their placement relative to nerves and neuronal cell bodies. Such devices include nerve-specific stimulators, neuroprosthetics, brainstem implants, and deep brain stimulators. Regardless of electrode location and interface type, acute and chronic histological, macroscopic and functional changes can occur as a result of both passive and active tissue responses to the bioelectric implant. CONCLUSION: A variety of chronically implantable electrodes have been developed to treat disorders of the peripheral and cranial nerves, to varying degrees of efficacy. Consideration and mitigation of detrimental effects at the neural interface with further optimization of functional nerve stimulation will facilitate the development of these technologies and translation to the clinic. LEVEL OF EVIDENCE: 3.

Chronic Subdural Hematoma: A Perspective on Subdural Membranes and Dementia.

OBJECTIVE: To review the complex pathogenesis of the subdural membrane and the link between head trauma, dementia, and dural lymphatics. METHODS: A thorough literature search of published English-language articles was performed using PubMed, Ovid, and Cochrane databases. RESULTS: Chronic subdural hematoma (cSDH) is a common intracranial pathology and a leading cause of reversible dementia. cSDH is projected to affect at least 60,000 new individuals in the United States annually by 2030. This condition can result from mild to moderate head trauma that leads to hemorrhaging in the dura-arachnoid interface. The short-term and long-term effects of cSDH and the subdural membrane on the pathogenesis of dementia and the newly discovered dural lymphatics is a topic of increasing importance. CONCLUSIONS: Further research into the possible link between traumatic brain injury and cSDH in particular and dural lymphatics and intracranial fluid dynamics is warranted.

Chronic Subdural Hematoma: A Historical and Clinical Perspective.

BACKGROUND: This review aims to highlight the clinical complexity of chronic subdural hematoma (cSDH) while presenting a brief historical discussion of cSDH. METHODS: A thorough literature search of published English-language papers was performed in PubMed, Ovid, and Cochrane databases. RESULTS: cSDH affects 1-5.3 per 100,000 individuals annually, with the incidence expected to rise as the U.S. population ages. The symptoms of cSDH are often nonspecific, with headaches being the most common complaint. Other symptoms include weakness, balance and gait problems, and memory problems. CONCLUSIONS: A variety of clinical factors must be taken into account in the treatment of cSDH, and the multifaceted treatment paradigms continue to evolve.

Linguistic Validation of Interactive Educational Interventions in Neurologic Trauma.

BACKGROUND: Neurological surgeons oftentimes educate patients and their families on complex medical conditions and treatment options. Time constraints and varied linguistic and cultural backgrounds limit the amount of information that can be disbursed. In this study, we assessed the linguistic validity of interactive educational interventions in non-English-speaking patients with traumatic brain injury (TBI) and concussion and their families. METHODS: A total of 273 English-, Spanish-, Korean-, and Vietnamese-speaking neurotrauma patients (n =124) and family members (n =149) completed a presurvey to evaluate their incipient understanding, interacted with an iPad-based iBook (Apple) on concussion or TBI in their native language, completed a postsurvey to gauge changes in understanding, and then consulted with their neurosurgeon. RESULTS: All participants (124 patients and 149 family members) had significantly increased (95% confidence interval [CI], P < 0.01) postsurvey scores (average pre-iBook score, 2.810; average post-iBook score, 4.109), regardless of native language or cultural background. Caucasian participants scored significantly higher than the combination of all ethnicities on both the baseline survey (95% CI, P < 0.01) and the post-iBook survey (95% CI, P < 0.01), and Asian participants scored significantly lower (95% CI, P < 0.05) than the combination regardless of similar baseline scores. CONCLUSIONS: Interactive iBook-based interventions on concussion and TBI can increase participants' comprehension, improve their comfort with their medical condition and the follow-up care, and enhance communication with their physicians. These findings are linguistically valid irrespective of the participants' native language or cultural background.

The Role of In-Office Ultrasound in the Diagnosis of Neck Masses.

To evaluate the efficacy of otolaryngologist-performed in-office ultrasound (US) in the clinical assessment of lateral neck masses, we performed a retrospective review of patients with lateral neck masses who had both a surgeon-performed US and US-guided fine-needle aspiration (USGFNA) at our tertiary academic center from 2012 to 2015. Fifty-nine patients were included. USGFNA results included 32 (54%) malignant lesions, 23 (39%) benign lesions, and 4 (6%) nondiagnostic lesions. USGFNA demonstrated 85% accuracy. In 22 (37%) patients, in-office US revealed additional findings that were not identified on physical examination (eg, nonpalpable lymph nodes or elucidated anatomical structures), which either assisted in surgical planning or altered treatment. In-office US and USGFNA on initial evaluation by the otolaryngologist augment physical examination and have potential value as the primary imaging and diagnostic modality in the workup of lateral neck masses.

Interactive iBook-Based Patient Education in a NeuroTrauma Clinic.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Educational interventions may alleviate the burden of TBI for patients and their families. Interactive modalities that involve engagement with the educational material may enhance patient knowledge acquisition when compared to static text-based educational material. OBJECTIVE: To determine the effects of educational interventions in the outpatient setting on self-reported patient knowledge, with a focus on iPad-based (Apple, Cupertino, California) interactive modules. METHODS: Patients and family members presenting to a NeuroTrauma clinic at a tertiary care academic medical center completed a presurvey assessing baseline knowledge of TBI or concussion, depending on the diagnosis. Subjects then received either an interactive iBook (Apple) on TBI or concussion, or an informative pamphlet with identical information in text format. Subjects then completed a postsurvey prior to seeing the neurosurgeon. RESULTS: All subjects (n = 152) significantly improved on self-reported knowledge measures following administration of either an iBook (Apple) or pamphlet (P < .01, 95% confidence interval [CI]). Subjects receiving the iBook (n = 122) performed significantly better on the postsurvey (P < .01, 95% CI), despite equivalent presurvey scores, when compared to those receiving pamphlets (n = 30). Lastly, patients preferred the iBook to pamphlets (P < .01, 95% CI). CONCLUSION: Educational interventions in the outpatient NeuroTrauma setting led to significant improvement in self-reported measures of patient and family knowledge. This improved understanding may increase compliance with the neurosurgeon's recommendations and may help reduce the potential anxiety and complications that arise following a TBI.

Interactive eBooks in educating patients and their families about head injury regardless of age.

OBJECTIVES: Traumatic Brain Injury (TBI) is a common and debilitating injury that is particularly prevalent in patients over 60. Given the influence of head injury on dementia (and vice versa), and the increased likelihood of ground-level falls, elderly patients are vulnerable to TBI. Educational interventions can increase knowledge and influence preventative activity to decrease the likelihood of further TBI. We sought to determine the efficacy of interactive tablet-based educational interventions in elderly patients on self-reported knowledge. PATIENTS AND METHODS: Patients and family members, ages 20-90, presenting to a NeuroTrauma clinic completed a pre-survey to assess baseline TBI or concussion knowledge, depending on their diagnosis. Participants then received an interactive electronic book (eBook), or a text-based pamphlet with identical information, and completed a post-survey to test interim knowledge improvement. RESULTS: All participants (n=180), regardless of age, had significantly higher post-survey scores (p<0.01, 95% CI). Elderly participants who received the eBook (n=39) scored lower than their younger counterparts despite higher pre-survey scores (p<0.01, 95% CI). All participants who received the eBook (n=20, 90) significantly improved on the post-survey (p<0.01, 95% CI) when compared to participants who received the paper pamphlets (n=10, 31). All participants significantly preferred the eBook (p<0.01, 95% CI). CONCLUSIONS: We demonstrated that interactive educational interventions are effective in the elderly TBI population. Enhanced educational awareness in the elderly population, especially patients at risk or with prior TBI, may prevent further head injury by educating patients on the importance of avoiding further head injury and taking precautionary measures to decrease the likelihood of further injury.

Use of interactive iBooks for patient education in otology.

INTRODUCTION: Physicians in the ambulatory setting face challenges in adequately educating patients in a brief office encounter. OBJECTIVE: To evaluate the efficacy of an iPad-based interactive educational module (iBook) in various otologic pathologies. METHODS: Patients presenting with symptoms of tinnitus, dizziness, hearing loss, or cochlear implant evaluation were included. In total, 44 patients received the iBook and 22 patients served as controls. Prior to viewing the iBook, patients completed a pre-survey to assess baseline knowledge. After viewing the iBook, patients completed a post-survey to assess changes in perception and knowledge of their disease. Results were compared to that of the control group who did not receive iBook supplementation prior to being seen by the physician. RESULTS: Paired t-test analysis showed significant improvements (p<0.01) in both self-reported perception and concrete understanding in various concepts when compared to pre-iBook results. This was further compared to the control group, which showed a significant gain in factual knowledge (p=0.02). CONCLUSION: Patients who viewed the iBook, personalized to their diagnosis, displayed significantly improved understanding of their condition. Increased use of interactive educational modalities, such as the iBook, can be of benefit to an otologic practice in improving patient education and satisfaction.

The Utility of In-Office Ultrasound in the Diagnosis of Parotid Lesions.

Objective To determine whether the use of in-office ultrasound (US) by a head and neck surgeon is a useful adjunct to clinical assessment of parotid lesions and decrease the need of additional imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT). Study Design Case series with chart review. Setting Tertiary care academic center. Subjects Seventy patients presenting with a parotid lesion who obtained an in-office US and ultrasound-guided fine-needle aspiration (USGFNA) from a head and neck surgeon from 2006 to 2015. Methods US images were retrospectively reviewed for 70 patients and characterized by a radiologist and a head and neck surgeon. Results Of the 70 patients, 6 had US characteristics that demonstrated a statistically significant association with a benign/malignant diagnosis: depth from surface; irregular borders; presence of calcifications, which included either micro- or macro-calcifications; posterior echogenicity enhancement; irregular shape; and homogeneous/heterogeneous echotexture. Imaging was performed prior to referral in 25 cases (35.7%); of those, 17 (68%) were for superficial, small (<2 cm) tumors where prereferral imaging studies did not provide additional information to that obtained with US. Of the 55 patients without MRI or CT performed prior to referral, MRI or positron emission tomography-CT scan was obtained in only 4 patients (7.3%) in cases involving recurrent parotid lesions, large tumors, or workup of a malignant neoplasm. Conclusions Several US characteristics individually assist in lesion characterization. In-office US and USGFNA are an appropriate first-line modality in the assessment of parotid lesions, can allow for immediate parotid lesion assessment, and can decrease the need for additional imaging.

Implementation of an Interactive Tablet-based Educational Intervention in the Neurotrauma Clinic: A 1-year Retrospective Analysis.

BACKGROUND: Traumatic Brain Injury (TBI) is a devastating and widely prevalent cause of death and disability in the United States. Educational interventions integrated into neurosurgical neurotrauma clinics can facilitate patient education and optimize the clinical encounter. Interactive educational modalities may enhance knowledge acquisition and patient satisfaction, however, no description of implementing such a program has been presented in the literature. The implementation of an interactive iBook-based educational intervention in an outpatient neurotrauma clinic is discussed. METHODS: Concussion and TBI iBooks and surveys were created. Then, a retrospective chart review and data analysis of 202 consecutive patients and family members presenting to the neurotrauma clinic was conducted. The participants completed a presurvey, reviewed an interactive iBook, and then completed a post-survey to test interim knowledge improvement. RESULTS: We discuss the process and problems encountered when creating the iBooks and implementing them in a clinical setting. Between August 1, 2015 and August 1, 2016, 93 patients (46%) and 109 (54%) family members participated in the study, for a total of 202 participants. 104 subjects reviewed a concussion iBook, and 98 subjects reviewed a TBI iBook, depending on their medical condition. Significant improvements in self-reported knowledge measures were demonstrated. Participants ranged in age from 10 to 90 years, with a mean of 45 years. The male to female ratio was 1.104:1. CONCLUSIONS: Interactive iBooks were readily implemented into a neurotrauma clinic. Improvements in self-reported knowledge measures and strong preference for the interactive iBook were attributed to the efficacy of the educational intervention. Examples of how interactive iBooks may be a useful adjunct in the education of head injury patients and their families in the neurotrauma setting are presented.