Lumbar Puncture Complications: A Review of Current Literature.

PURPOSE OF REVIEW: This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. RECENT FINDINGS: Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

NTRK-rearranged spindle cell neoplasm: Initial observation of imaging appearance and clinicopathologic correlation.

OBJECTIVE: To explore pre-treatment imaging findings of neurotrophic tyrosine receptor kinase (NTRK)-rearranged spindle cell neoplasm, an emerging group of molecularly defined soft tissue tumors and summarize the clinical course, including TRK inhibitor therapy response. MATERIALS AND METHODS: This retrospective study included 8 women and 4 men with NTRK-rearranged spindle cell neoplasm (median age, 35.5 years, range, 0-66). Available pre-treatment MRI, CT, PET, and US imaging were reviewed. Tumor histology and the patients' clinical course were reviewed. RESULTS: Primary tumors were located within the soft tissue, lungs, kidney, and breast with soft tissue being the most prevalent site (n = 6). Pre-treatment MRI (n = 4) revealed linear hypointense signal foci and contrast enhancement in all patients with hemorrhage in half of the tumors. A tail sign (n = 1) and fluid levels (n = 1) were less frequent. Ultrasound showed well-marginated hypoechoic masses with internal flow. Primary tumors were all non-calcified on CT (4/4). Metastases were FDG-avid (4/4). Among the 8 patients who developed metastasis, 7 developed pulmonary metastases. All four patients who received NTRK inhibitor therapy showed an initial decrease in tumor size or FDG uptake. CONCLUSION: NTRK-rearranged neoplasms may occur as enhancing masses with linear hypointense signal foci on MRI and FDG avid metastases on PET. Pulmonary metastases were frequent in our study. Initial treatment response is observed in most patients.

Acute post-injury blockade of α2δ-1 calcium channel subunits prevents pathological autonomic plasticity after spinal cord injury.

After spinal cord injury (SCI), normally innocuous visceral or somatic stimuli can trigger uncontrolled reflex activation of sympathetic circuitry, causing pathological dysautonomia. We show that remarkable structural remodeling and plasticity occur within spinal autonomic circuitry, creating abnormal sympathetic reflexes that promote dysautonomia. However, when mice are treated early after SCI with human-equivalent doses of the US Food and Drug Administration (FDA)-approved drug gabapentin (GBP), it is possible to block multi-segmental excitatory synaptogenesis and abolish sprouting of autonomic neurons that innervate immune organs and sensory afferents that trigger pain and autonomic dysreflexia (AD). This "prophylactic GBP" regimen decreases the frequency and severity of AD and protects against SCI-induced immune suppression. These benefits persist even 1 month after stopping treatment. GBP could be repurposed to prevent dysautonomia in at-risk individuals with high-level SCI.

Vaccine Hesitancy in Pediatric Primary Care Practices.

Understanding how pediatric practices handle parental vaccine hesitancy is important as it impacts the efficiency and effectiveness of pediatric practices. In total, 21 semi-structured interviews with pediatric practice staff within a primary care network were conducted between May 2012 and March 2013. Thematic analysis focused on the barriers and challenges of vaccine hesitancy and strategies to reduce the burden at the practice level. Barriers and challenges of vaccine hesitancy included time constraints, administrative challenges, financial challenges and strained patient-provider relationships. Strategies to minimize the burden of vaccine hesitancy included training for vaccine counseling, screening for vaccine hesitancy prior to immunization visits, tailored vaccine counseling, and primary care provider visits for follow-up immunization. Pediatric practices reported many challenges when caring for vaccine-hesitant families. Multiple strategies were identified to reduce the burden of vaccine hesitancy, which future studies should explore to determine how effective they are in increasing vaccine acceptance in pediatric practices.

Medical retirement from sport after concussions: A practical guide for a difficult discussion.

PURPOSE OF REVIEW: In patients with a considerable history of sports-related concussion, the decision of when to discontinue participation in sports due to medical concerns including neurologic disorders has potentially life-altering consequences, especially for young athletes, and merits a comprehensive evaluation involving nuanced discussion. Few resources exist to aid the sports medicine provider. RECENT FINDINGS: In this narrative review, we describe 10 prototypical vignettes based upon the authors' collective experience in concussion management and propose an algorithm to help clinicians navigate retirement discussions. Issues for consideration include absolute and relative contraindications to return to sport, ranging from clinical or radiographic evidence of lasting neurologic injury to prolonged concussion recovery periods or reduced injury threshold to patient-centered factors including personal identity through sport, financial motivations, and navigating uncertainty in the context of long-term risks. SUMMARY: The authors propose a novel treatment algorithm based on real patient cases to guide medical retirement decisions after concussion in sport.

Sex-specific Outcomes and Predictors of Concussion Recovery.

INTRODUCTION: Sports-related concussion (SRC) is a substantial concern in collegiate athletics. Some studies of SRC that make comparisons by sex are limited by sample size, follow-up duration, or referral bias. Sex-specific predictors of occurrence and recovery are uncertain. METHODS: A 15-year retrospective cohort study identified 1,200 Columbia University varsity athletes (822 male [68.5%], 378 female [31.5%]) at risk of collegiate SRC. RESULTS: A total of 228 athletes experienced at least one collegiate concussion, including 88 female athletes (23.3% of female athletes) and 140 male athletes (17.0% of male athletes) (P = 0.01); follow-up data were available on 97.8% of these athletes. Postconcussion symptoms were similar by sex, with the exception of sleep disturbance (29.3% of male athletes versus 42.0% of female athletes; P = 0.048) and memory impairment (43.6% of male athletes versus 30.7% of female athletes; P = 0.052), although the latter difference was not statistically significant. Risk factors for collegiate concussion included female sex (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1 to 2.0) or precollegiate concussion (OR, 2.9; 95% CI, 2.2 to 3.9). Prolonged recovery was predicted by the presence of eight or more postconcussion symptoms for all athletes (OR, 3.77; 95% CI, 1.68 to 8.46) and for female athletes only (OR, 8.24; 95% CI, 1.58 to 43.0); this finding was not statistically significant for male athletes. DISCUSSION: Female athletes were more likely than male athletes to experience concussion. Increasing numbers of prior concussions predicted recurrence. Although most postconcussion symptoms were highly intercorrelated, the total number of symptoms predicted a prolonged recovery period. CONCLUSION: This study confirms sex-based differences in SRCs. Longitudinal studies of collegiate cohorts should attempt to limit follow-up bias and offer opportunities to clarify determinants of SRC.

Nonmedical exemptions from school immunization requirements: a systematic review.

We summarized studies describing the prevalence of, trends in, and correlates of nonmedical exemptions from school vaccination mandates and the association of these policies with the incidence of vaccine-preventable disease. We searched 4 electronic databases for empirical studies published from 1997 to 2013 to capture exemption dynamics and qualitatively abstracted and synthesized the results. Findings from 42 studies suggest that exemption rates are increasing and occur in clusters; most exemptors questioned vaccine safety, although some exempted out of convenience. Easier state-level exemption procedures increase exemption rates and both individual and community disease risk. State laws influence exemption rates, but policy implementation, exemptors' vaccination status, and underlying mechanisms of geographical clustering need to be examined further to tailor specific interventions.