Histone content, and thus DNA content, is associated with differential in vitro lysis of acute ischemic stroke clots.

BACKGROUND: Fibrin, von Willebrand factor, and extracellular DNA from neutrophil extracellular traps all contribute to acute ischemic stroke thrombus integrity. OBJECTIVES: In this study, we explored how the proteomic composition of retrieved thromboemboli relates to susceptibility to lysis with distinct thrombolytics. METHODS: Twenty-six retrieved stroke thromboemboli were portioned into 4 segments, with each subjected to 1 hour of in vitro lysis at 37 °C in 1 of 4 solutions: tissue plasminogen activator (tPA), tPA + von Willebrand factor-cleaving ADAMTS-13, tPA + DNA-cleaving deoxyribonuclease (DNase) I, and all 3 enzymes. Lysis, characterized by the percent change in prelysis and postlysis weight, was compared across the solutions and related to the corresponding abundance of proteins identified on mass spectrometry for each of the thromboemboli used in lysis. RESULTS: Solutions containing DNase resulted in approximately 3-fold greater thrombolysis than that with the standard-of-care tPA solution (post hoc Tukey, P < .01 for all). DNA content was directly related to lysis in solutions containing DNase (Spearman's ρ > 0.39 and P < .05 for all significant histones) and inversely related to lysis in solutions without DNase (Spearman's ρ < -0.40 and P < .05 for all significant histones). Functional analysis suggests distinct pathways associated with susceptibility to thrombolysis with tPA (platelet-mediated) or DNase (innate immune system-mediated). CONCLUSION: This study demonstrates synergy of DNase and tPA in thrombolysis of stroke emboli and points to DNase as a potential adjunct to our currently limited selection of thrombolytics in treating acute ischemic stroke.

Management of postoperative cervical pseudomeningocele with percutaneous aspiration and epidural blood patch.

INTRODUCTION: While epidural blood patch can be an effective management option in lumbar pseudomeningoceles in certain clinical settings, its utility in the cervical spine is unclear. The aim of this study was to evaluate the safety and effectiveness of percutaneous aspiration and autologous blood patch for post-operative durotomy related pseudomeningoceles within the cervical spine. METHODS: A single institution retrospective review detailing 3 patients with durotomy related pseudomeningocele following posterior cervical spine surgery was completed. RESULTS: In all three cases, aspiration with subsequent injection of autologous epidural blood patch successfully treated each pseudomeningocele. One patient required more than one intervention, while the other two were successfully treated after one procedure. All three patients improved clinically without need for additional surgery. CONCLUSION: Percutaneous aspiration and epidural blood patch can be used to safely manage post-operative pseudomeningoceles within the posterior cervical spine.

Transarterial Yttrium-90 Radioembolization for Unresectable Intrahepatic Cholangiocarcinoma: A Systematic Review and Meta-Analysis.

PURPOSE: To investigate the overall efficacy and survival profile of yttrium-90 (90Y) radioembolization for unresectable intrahepatic cholangiocarcinoma (ICC). MATERIALS AND METHODS: A systematic literature review and meta-analysis was completed using a random-effects model. Studies describing the use of 90Y for unresectable ICC were included. The disease control rate (DCR), downstaged-to-resectable rate, cancer antigen 19-9 (CA19-9) response rate, pooled median overall survival (OS), pooled median progression-free survival (PFS), and mean reported survival rates ranging from 3 to 36 months were evaluated. RESULTS: Twenty-one studies detailing a total of 921 patients were included. The overall DCR was 82.3% (95% confidence interval [CI], 76.7%-87.8%; I2 = 81%). In 11% of the cases, patients were downstaged to being surgically resectable (95% CI, 6.1%-15.9%; I2 = 78%). The CA19-9 response rate was 67.2% (95% CI, 54.5%-79.8%; I2 = 60%). From the time of radioembolization, PFS was 7.8 months (95% CI, 4.2-11.3 months; I2 = 94%) and median OS was 12.7 months (95% CI, 10.6-14.8 months; I2 = 62%). Lastly, the mean overall reported survival proportions were 84% at 3 months (standard deviation [SD], 10%), 69% at 6 months (SD, 16%), 47% at 12 months (SD, 19%), 31% at 18 months (SD, 21%), 30% at 24 months (SD, 19%), 21% at 30 months (SD, 27%), and 5% at 36 months (SD, 7%). CONCLUSIONS: Radioembolization with 90Y for unresectable ICC results in substantial downstaging, disease control, and survival.

Trends in Medicare Reimbursement for Otology Procedures From 2000 to 2020.

OBJECTIVE: The purpose of this study is to investigate the Medicare reimbursement trends for otologic procedures from 2000 to 2020. STUDY DESIGN: Retrospective data analysis using the Physician Fee Schedule Look-Up tool from the Centers for Medicare and Medicaid services. SETTING: Facility performed procedures of the auditory system. PATIENTS: Medicare beneficiaries from 2000 to 2020. INTERVENTIONS: Selected otologic current procedural terminology codes and their respective year-to-year reimbursement data. MAIN OUTCOME MEASURES: Assessment of trends in financial reimbursement. RESULTS: After adjusting for inflation, the total average reimbursement for all procedures saw an average decrease of -21.2% from 2000 to 2020. The average adjusted percent change per year was -1.3% indicating a slow decline in reimbursement over the study period. There was a difference between the adjusted and unadjusted percent change in reimbursement rate during the study period (-21% versus 20.4%, respectively; p < 0.001). Linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2000 to 2020 with an R-squared value of 0.85 indicating a decline in reimbursement over time. CONCLUSIONS: After adjusting all data for inflation, there has been a reduction in the average Medicare reimbursement for otology procedures from 2000 to 2020. Compared with previous reimbursement studies on the whole field of otolaryngology, otology has a less severe decline in reimbursement. Knowledge of these reimbursement trends is critical for otologic surgeons and leaders within the field to develop more sustainable reimbursement plans.

A Rare Case of Odontogenic Chronic Suppurative Otitis Media.

Common causes of chronic suppurative otitis media (CSOM) include persistence of acute otitis media, cholesteatoma, and eustachian tube dysfunction. We describe a patient who presented with CSOM of several years duration refractory to medical management. Ultimately, a dental abscess was found on computed tomography (CT) to be the source of concurrent ipsilateral maxillary sinusitis and mastoiditis. Extraction of the molar abscess resulted in complete resolution of her CSOM and need to be on antibiotics. To our knowledge, this is the first report of an odontogenic cause of chronic suppurative otitis media.

Cervicothoracic epidural hematoma in a toddler with miosis, ptosis, nonspecific symptoms, and no history of major trauma: case report.

INTRODUCTION: Spinal epidural hematomas are uncommon in children. The diagnosis can be elusive as most cases present without a history of trauma, while symptoms can be atypical. CASE REPORT: We encountered a 35-month-old male presenting with nonspecific symptoms and no history of trauma. He later developed unilateral miosis and ptosis; MRI discovered a subacute cervicothoracic epidural which was promptly evacuated. The patient made an excellent recovery. COCLUSIONS: We emphasize the frequent absence of identifiable trauma and the importance of thorough imaging when this entity is suspected. Miosis and ptosis, likely representing a partial Horner syndrome, is an extremely rare presentation, this being one of the only reported cases.