Popularizing Surgical Cures: Walter Dandy and the Vestibular Neurectomy for Menière's Disease at the Johns Hopkins Hospital.

OBJECTIVES: To uncover the context that allowed for the vestibular neurectomy to grow in favor and practice at the Johns Hopkins Hospital in the early 20th century, and the reasons for its broad abandonment since. METHODS: The Walter E. Dandy (1905-1946) and Samuel J. Crowe collections (1905-1920) at the Alan Mason Chesney Medical Archives were reviewed, as well as the Samuel J. Crowe and Stacy Guild Temporal Bone Collection. RESULTS: Speculation on the etiology of Menière's disease (MD) has been countless, as have the medical and surgical interventions aimed at treating it. At the Johns Hopkins Hospital, Walter Dandy popularized the neurectomy for MD and performed 692 procedures from 1924 to 1946, believing it to be a curative therapy for vertigo. When he later modified the procedure from a total cranial nerve section to a partial vestibular neurectomy preserving auditory function, surgical candidacy expanded to include nearly any patient with vestibular symptoms. After his passing, trainees' attention shifted to traumatic injuries, likely influenced by WWII. This left the procedure scarcely used until third parties rekindled interest decades later. CONCLUSIONS: Neurectomy as the preferential treatment for MD at the Johns Hopkins Hospital was not driven by pure scientific reasoning but was rather contingent on historical context and sponsorship by a prominent figure like Walter Dandy. Appreciation of MD's natural history has since curtailed the favorability of destructive procedures in preference for conservative management.

Agent-based modeling of the COVID-19 pandemic in Florida.

The onset of the COVID-19 pandemic drove a widespread, often uncoordinated effort by research groups to develop mathematical models of SARS-CoV-2 to study its spread and inform control efforts. The urgent demand for insight at the outset of the pandemic meant early models were typically either simple or repurposed from existing research agendas. Our group predominantly uses agent-based models (ABMs) to study fine-scale intervention scenarios. These high-resolution models are large, complex, require extensive empirical data, and are often more detailed than strictly necessary for answering qualitative questions like "Should we lockdown?" During the early stages of an extraordinary infectious disease crisis, particularly before clear empirical evidence is available, simpler models are more appropriate. As more detailed empirical evidence becomes available, however, and policy decisions become more nuanced and complex, fine-scale approaches like ours become more useful. In this manuscript, we discuss how our group navigated this transition as we modeled the pandemic. The role of modelers often included nearly real-time analysis, and the massive undertaking of adapting our tools quickly. We were often playing catch up with a firehose of evidence, while simultaneously struggling to do both academic research and real-time decision support, under conditions conducive to neither. By reflecting on our experiences of responding to the pandemic and what we learned from these challenges, we can better prepare for future demands.

Changes in Donor Utilization and Outcomes for Patients Bridged With Durable Left Ventricular Assist Device.

We studied the impact of the 2018 heart allocation policy change on donor characteristics and posttransplant outcomes of left ventricular assist device (LVAD)-bridged heart transplant (HT) recipients. Left ventricular assist device-bridged adult HT recipients from October 2014 to October 2022 in the United Network for Organ Sharing database were categorized into old allocation policy (OAP) and new allocation policy (NAP) cohorts. Baseline characteristics, posttransplant outcomes, and subgroup analyses of unstable and stable LVAD-bridged recipients were assessed. The study included 7,384 HT recipients; 4,345 (58.8%) were transplanted in the OAP era and 3,039 (41.2%) in the NAP era. Old allocation policy recipients were most frequently status 1A at transplantation (71.1%), whereas NAP recipients were most frequently status 3 (40.0%), and status 4 (31.9%). Median donor sequence number (DSN) was higher in the NAP versus OAP era (9 vs. 3, p < 0.001). On multivariable analysis, NAP recipients had 20% higher 1 year mortality compared to OAP (adjusted hazard ratio [aHR] = 1.20 [95% confidence interval {CI}: 1.04-1.40], p = 0.01). Status 1 or 2 recipients had 28% higher 1 year mortality compared to status 1A (aHR = 1.28 [95% CI: 1.01-1.63], p = 0.04). Status 1 and 2 LVAD-supported recipients had higher mortality following the 2018 allocation change, indicating the need for closer surveillance of LVAD-bridged patients who may decompensate on the waitlist.

SVPath: A Deep Learning Tool for Analysis of Stria Vascularis from Histology Slides.

INTRODUCTION: The stria vascularis (SV) may have a significant role in various otologic pathologies. Currently, researchers manually segment and analyze the stria vascularis to measure structural atrophy. Our group developed a tool, SVPath, that uses deep learning to extract and analyze the stria vascularis and its associated capillary bed from whole temporal bone histopathology slides (TBS). METHODS: This study used an internal dataset of 203 digitized hematoxylin and eosin-stained sections from a normal macaque ear and a separate external validation set of 10 sections from another normal macaque ear. SVPath employed deep learning methods YOLOv8 and nnUnet to detect and segment the SV features from TBS, respectively. The results from this process were analyzed with the SV Analysis Tool (SVAT) to measure SV capillaries and features related to SV morphology, including width, area, and cell count. Once the model was developed, both YOLOv8 and nnUnet were validated on external and internal datasets. RESULTS: YOLOv8 implementation achieved over 90% accuracy for cochlea and SV detection. nnUnet SV segmentation achieved a DICE score of 0.84-0.95; the capillary bed DICE score was 0.75-0.88. SVAT was applied to compare both the ears used in the study. There was no statistical difference in SV width, SV area, and average area of capillary between the two ears. There was a statistical difference between the two ears for the cell count per SV. CONCLUSION: The proposed method accurately and efficiently analyzes the SV from temporal histopathology bone slides, creating a platform for researchers to understand the function of the SV further.

The Society of Thoracic Surgeons Looking to the Future Scholarship Program: A 15-Year Review.

BACKGROUND: It has been postulated that a possible barrier to pursuing cardiothoracic surgery is a lack of exposure and mentorship during training. In 2006, The Society of Thoracic Surgeons began the Looking to the Future Scholarship to expand interest in the field. Undecided trainees with limited exposure were prioritized in the selection process. This report summarizes the career outcomes of general surgery resident and medical student recipients. METHODS: Scholarship recipients and nonrecipients (control) were queried in a Google search. The percentage of those who were cardiothoracic surgeons or in cardiothoracic training (%CTS) was calculated, as well as the percentage of female surgeons in cardiothoracic surgery. RESULTS: From 2006 to 2021, there were 669 awardees. The %CTS was 63.7% for resident recipients and 31.4% for students, respectively. There was no significant difference in %CTS between resident and student recipients compared to nonrecipients. Notably, the percentage of female cardiothoracic surgeons was significantly greater for both resident and student recipients. CONCLUSIONS: The majority of resident recipients are now in cardiothoracic surgery, comparable to nonrecipients. While there was no significant difference between the percentage of recipients and non-recipients in cardiothoracic surgery, these groups differed substantially as nonrecipients had greater exposure and commitment to the field at the time of application.

Historical Therapies for Suspected Autonomic Dysregulation in Meniere's Disease.

OBJECTIVE: This narrative review examines how speculative belief that the autonomic nervous system causes Meniere's Disease (MD) led otolaryngologists to adopt invasive surgical procedures and medical treatments still offered today. DATA SOURCES: Google Scholar, PubMed. REVIEW METHODS: A comprehensive literature review (1860-2022) was performed using the terms "Meniere AND (sympathetic OR sympathectomy OR vasomotor OR cervical ganglion)," returning 5360 items. All abstracts were briefly reviewed, relevant publications selected for further study, and key articles discussed by all authors. As it became clear that betahistine was related to the historical narrative, an additional search was performed using "Betahistine AND Meniere AND (vasomotor OR sympathetic OR sympathectomy OR cervical ganglion OR autonomic)," which yielded 336 results. RESULTS: In the 19th and 20th centuries, growing knowledge of human anatomy led the scientific community to speculate that autonomic dysregulation caused many medical conditions. Excessive sympathetic mediated vasomotor changes were thought to cause hypertension, ischemia, and tissue damage. Clinicians applied the hypothesis to MD, assigning the sympathetic nervous system responsible for vertigo secondary to paroxysmal vasospasm and for hearing loss to poor cochlear nutrition. Despite limited animal experiments and isolated clinical observations, otolaryngologists performed sympathectomies, and, in the 1970s, replaced the procedure with betahistine as an alternative medical treatment. CONCLUSION: Premature excitement about a plausible hypothesis led to unnecessary and unwarranted operations. Despite absent evidence of sympathetic overactivation in MD, surgeons eagerly adopted sympathectomies, and later betahistine. Rigorous evaluation of the validity of these treatment practices is needed. LEVEL OF EVIDENCE: 5 Laryngoscope, 134:535-542, 2024.

Multiple models for outbreak decision support in the face of uncertainty.

Policymakers must make management decisions despite incomplete knowledge and conflicting model projections. Little guidance exists for the rapid, representative, and unbiased collection of policy-relevant scientific input from independent modeling teams. Integrating approaches from decision analysis, expert judgment, and model aggregation, we convened multiple modeling teams to evaluate COVID-19 reopening strategies for a mid-sized United States county early in the pandemic. Projections from seventeen distinct models were inconsistent in magnitude but highly consistent in ranking interventions. The 6-mo-ahead aggregate projections were well in line with observed outbreaks in mid-sized US counties. The aggregate results showed that up to half the population could be infected with full workplace reopening, while workplace restrictions reduced median cumulative infections by 82%. Rankings of interventions were consistent across public health objectives, but there was a strong trade-off between public health outcomes and duration of workplace closures, and no win-win intermediate reopening strategies were identified. Between-model variation was high; the aggregate results thus provide valuable risk quantification for decision making. This approach can be applied to the evaluation of management interventions in any setting where models are used to inform decision making. This case study demonstrated the utility of our approach and was one of several multimodel efforts that laid the groundwork for the COVID-19 Scenario Modeling Hub, which has provided multiple rounds of real-time scenario projections for situational awareness and decision making to the Centers for Disease Control and Prevention since December 2020.

Traumatic Axonal Injury in the Optic Nerve: The Selective Role of SARM1 in the Evolution of Distal Axonopathy.

Traumatic axonal injury (TAI), thought to be caused by rotational acceleration of the head, is a prevalent neuropathology in traumatic brain injury (TBI). TAI in the optic nerve is a common finding in multiple blunt-force TBI models and hence a great model to study mechanisms and treatments for TAI, especially in view of the compartmentalized anatomy of the visual system. We have previously shown that the somata and the proximal, but not distal, axons of retinal ganglion cells (RGC) respond to DLK/LZK blockade after impact acceleration of the head (IA-TBI). Here, we explored the role of the sterile alpha and TIR-motif containing 1 (SARM1), the key driver of Wallerian degeneration (WD), in the progressive breakdown of distal and proximal segments of the optic nerve following IA-TBI with high-resolution morphological and classical neuropathological approaches. Wild type and Sarm1 knockout (KO) mice received IA-TBI or sham injury and were allowed to survive for 3, 7, 14, and 21 days. Ultrastructural and microscopic analyses revealed that TAI in the optic nerve is characterized by variable involvement of individual axons, ranging from apparent early disconnection of a subpopulation of axons to a range of ongoing axonal and myelin perturbations. Traumatic axonal injury resulted in the degeneration of a population of axons distal and proximal to the injury, along with retrograde death of a subpopulation of RGCs. Quantitative analyses on proximal and distal axons and RGC somata revealed that different neuronal domains exhibit differential vulnerability, with distal axon segments showing more severe degeneration compared with proximal segments and RGC somata. Importantly, we found that Sarm1 KO had a profound effect in the distal optic nerve by suppressing axonal degeneration by up to 50% in the first 2 weeks after IA-TBI, with a continued but lower effect at 3 weeks, while also suppressing microglial activation. Sarm1 KO had no evident effect on the initial traumatic disconnection and did not ameliorate the proximal optic axonopathy or the subsequent attrition of RGCs, indicating that the fate of different axonal segments in the course of TAI may depend on distinct molecular programs within axons.

A pilot randomized controlled trial of group-based indoor gardening and art activities demonstrates therapeutic benefits to healthy women.

BACKGROUND: There is mounting anecdotal and empirical evidence that gardening and art-making afford therapeutic benefits. OBJECTIVES: This randomly controlled pilot study tested the hypothesis that participation in group-based indoor gardening or art-making activities for one hour twice a week for four weeks would provide quantifiably different therapeutic benefits to a population of healthy women ages 26-49. METHODS: A population of 42 volunteers was randomly assigned to parallel gardening or art-making treatment groups. A total of 36 participants initiated the treatment protocol and 32 (Gardening n = 15 and Art n = 17) received the interventions and completed all assessments. Treatments included eight one-hour group-based gardening or art intervention sessions. Self-report psychometric assessments were conducted for anxiety, depression symptomatology, mood disturbance, stress, satisfaction with discretionary social activities, and quality of life measures. Cardiac physiological data were also collected. Outcomes were measured at baseline, during, and post-intervention. RESULTS: Engaging in both gardening and art-making activities resulted in apparent therapeutic improvements for self-reported total mood disturbance, depression symptomatology, and perceived stress with different effect sizes following eight one-hour treatment sessions. Gardening also resulted in improvements for indications of trait anxiety. Based on time-course evidence, dosage responses were observed for total mood disturbance, perceived stress, and depression symptomatology for both gardening and art-making. However, gardening or art-making did not have an apparent influence on heart rate or blood pressure or result in marked improvement for satisfaction with discretionary leisure activities. CONCLUSION: The data did not support the hypothesis of differential therapeutic benefits of gardening and art-making for healthy women. When taken together, group-based gardening or art-making can provide quantitatively measurable improvements in healthy women's psychosocial health status that imply potentially important public health benefits. TRIAL REGISTRATION: ClinicalTrials.gov NCT03266120.

Should coronavirus policies remain in place to prevent future paediatric influenza deaths?

The 2019-2020 to 2020-2021 influenza seasons in the USA saw a dramatic 99.5% decrease in paediatric mortality, with only one influenza death recorded during the latter season. This decrease has been attributed to a substantial reduction in transmission, resulting from the various restrictive measures enacted during the COVID-19 pandemic, onset March 2020. The relative disappearance of influenza raises specific policy questions, such as whether these measures should be kept in place after COVID-19 transmission reaches acceptable levels or herd immunity is achieved. Given the nature of these measures as liberty restricting, it is worth discussing their intended outcome and what values they promote. Do these measures in fact promote health, or simply give the comfort of safety while undermining long-term health and individual liberties? I argue that the year-long endurance of the pandemic well into 2021 may have flattened our value landscape into one where health reigns supreme. Discussions are underway regarding whether we should modify previously accepted health risks, such as the risk of contracting influenza. In this paper, I attempt to clarify the values that motivate our policies and discuss how our present historical context has appreciated the value of health. I also provide an analysis of various pandemic policies and their relation to influenza paediatric deaths. Ultimately, the cost of certain measures on values such as education, socialisation and liberty, among others, is too high to justify their use beyond regulating the spread of COVID-19.

COVID-19 reopening strategies at the county level in the face of uncertainty: Multiple Models for Outbreak Decision Support.

Policymakers make decisions about COVID-19 management in the face of considerable uncertainty. We convened multiple modeling teams to evaluate reopening strategies for a mid-sized county in the United States, in a novel process designed to fully express scientific uncertainty while reducing linguistic uncertainty and cognitive biases. For the scenarios considered, the consensus from 17 distinct models was that a second outbreak will occur within 6 months of reopening, unless schools and non-essential workplaces remain closed. Up to half the population could be infected with full workplace reopening; non-essential business closures reduced median cumulative infections by 82%. Intermediate reopening interventions identified no win-win situations; there was a trade-off between public health outcomes and duration of workplace closures. Aggregate results captured twice the uncertainty of individual models, providing a more complete expression of risk for decision-making purposes.