Comparing Magnetic Resonance Imaging and Prostate-Specific Membrane Antigen-Positron Emission Tomography for Prediction of Extraprostatic Extension of Prostate Cancer and Surgical Guidance: A Prospective Nonrandomized Clinical Trial.

PURPOSE: Survivors of surgically managed prostate cancer may experience urinary incontinence and erectile dysfunction. Our aim was to determine if 68Ga-prostate-specific membrane antigen-11 positron emission tomography CT (PSMA-PET) in addition to multiparametric (mp) MRI scans improved surgical decision-making for nonnerve-sparing or nerve-sparing approach. MATERIALS AND METHODS: We prospectively enrolled 50 patients at risk for extraprostatic extension (EPE) who were scheduled for prostatectomy. After mpMRI and PSMA-PET images were read for EPE prediction, surgeons prospectively answered questionnaires based on mpMRI and PSMA-PET scans on the decision for nerve-sparing or nonnerve-sparing approach. Final whole-mount pathology was the reference standard. Sensitivity, specificity, positive predictive value, negative predictive value, and receiver operating characteristic curves were calculated and McNemar's test was used to compare imaging modalities. RESULTS: The median age and PSA were 61.5 years and 7.0 ng/dL. The sensitivity for EPE along the posterior neurovascular bundle was higher for PSMA-PET than mpMRI (86% vs 57%, P = .03). For MRI, the specificity, positive predictive value, negative predictive value, and area under the curve for the receiver operating characteristic curves were 77%, 40%, 87%, and 0.67, and for PSMA-PET were 73%, 46%, 95%, and 0.80. PSMA-PET and mpMRI reads differed on 27 nerve bundles, with PSMA-PET being correct in 20 cases and MRI being correct in 7 cases. Surgeons predicted correct nerve-sparing approach 74% of the time with PSMA-PET scan in addition to mpMRI compared to 65% with mpMRI alone (P = .01). CONCLUSIONS: PSMA-PET scan was more sensitive than mpMRI for EPE along the neurovascular bundles and improved surgical decisions for nerve-sparing approach. Further study of PSMA-PET for surgical guidance is warranted in the unfavorable intermediate-risk or worse populations. CLINICALTRIALS.GOV IDENTIFIER: NCT04936334.

Deep Brain Stimulation for Multiple Sclerosis Tremor: A Meta-Analysis.

OBJECTIVES: To examine the effect of deep brain stimulation (DBS) on multiple sclerosis (MS)-tremor, as measured by a normalized scale of tremor severity, with a meta-analysis of the published literature. METHODS: Medline and EBSCO Host (January, 1998 to June, 2018) were systematically reviewed with librarian guidance, using the keywords "Deep brain stimulation" and "multiple sclerosis." Bibliographies and experts in the field were also consulted to identify missed articles. All therapeutic studies on DBS for MS-tremor, reported in the English language, within the study period were included. Papers that reported outcomes without a measure of central tendency and/or distribution were excluded. The papers were read in their entirety and graded for risk of bias according to the American Academy of Neurology (AAN) standards. To maximize statistical power, papers using different stimulation targets were grouped together. Outcomes were reported with the Fahn-Tolosa-Marin scale (FTM), the Bain-Finchley scale (CRS) and 3- and 4-point tremor severity scales and normalized with a Hedges g. RESULTS: The search produced 13 studies suitable for meta-analysis. The random-effects meta-analysis showed that DBS improved the Hedges standardized mean tremor score by 2.86 (95%CI 2.03-3.70, p < .00001). Heterogeneity was high, with an I2 of 84%, suggesting that random effects model is more appropriate. Adverse event rates varied from 8% to 50%. CONCLUSIONS: This meta-analysis provides level III evidence that DBS may improve MS-related tremor as measured by standardized tremor severity scales.

Incidence of Atrial Fibrillation in Large Vessel Occlusion and Large Embolic Stroke of Undetermined Source.

INTRODUCTION: Large vessel occlusion (LVO) stroke is a common presentation of acute ischemic stroke and is often unknown or cryptogenic in etiology. There is a strong association between atrial fibrillation (AF) and cryptogenic LVO stroke, making it a unique stroke subgroup. Therefore, we propose that any LVO stroke meeting the criteria for an embolic stroke of an undetermined source (ESUS) be classified as large ESUS (LESUS). The purpose of this retrospective cohort study was to report the etiology of anterior LVO strokes that underwent endovascular thrombectomy. METHODS: This was a single-center retrospective cohort study characterizing the etiology of acute anterior circulation LVO strokes that received emergent endovascular thrombectomy from 2011 to 2018. Patients with LESUS designation at hospital discharge were changed to cardioembolic etiology if AF was discovered during the two-year follow-up period.  Results: Overall, 155 (45%) of 307 patients in the study were found to have AF. New onset AF was discovered in 12 (23%) of 53 LESUS patients after hospitalization. Furthermore, eight (35%) of 23 LESUS patients who received extended cardiac monitoring were found to have AF. CONCLUSION: Nearly half the patients with LVO stroke who received endovascular thrombectomy were found to have AF. With the use of extended cardiac monitoring devices after hospitalization, AF is frequently discovered in patients with LESUS and may change the secondary stroke prevention strategy.

Elective surgery for acute pain in patients with substance use disorder: lessons learned at a rural neurosurgical center. Patient series.

BACKGROUND: The incidence of pain-generating degenerative spinal problems in patients who are currently using or have previously used drugs has increased as substance use disorder (SUD) becomes a chronic, lifelong condition. Health system-level data in recent years indicate a significant increase in patients with coexisting SUD and degenerative disc disease, representing an emerging population. A retrospective electronic medical record review identified seven patients with SUD who underwent elective spine surgery by orthopedic or neurosurgical staff from 2012 to 2021. The authors present two of these illustrative cases and a framework that can be used in the treatment of similar patients. OBSERVATIONS: Substances used included opioids, benzodiazepines, barbiturates, cocaine, methamphetamines, hallucinogens, lysergic acid diethylamide, phencyclidine, and cannabis. All were abstaining from drug use preoperatively, with four patients in a formal treatment program. Five patients were discharged with an opioid prescription, and two patients deferred opioids. Three experienced a relapse of substance use within 1 year. All patients presented for follow-up, although two required additional contact for follow-up compliance. LESSONS: Perioperative protocols focusing on patient-led care plans, pain control, communication with medication for opioid use disorder providers, family and social support, and specific indicators of possible poor results can contribute to better outcomes for care challenges associated with these diagnoses.

Survival outcomes in node-positive non-metastatic bladder cancer: An analysis of the national cancer database.

Introduction: Clinically node-positive non-metastatic bladder cancer (cN+) has been the target of several studies aiming to establish a standard of care for this population. Limited studies have shown a survival benefit for various multimodal therapy approaches. The role of radiation therapy has not been well established. Our study aims to study the trends of the reported treatment options offered to patients with cN+ bladder cancer in a national database and to evaluate the effect of various treatments, including radiation, on survival. Methods: The National Cancer Database (NCDB) was used to identify cN+ bladder cancer patients who received chemotherapy alone or in combination with radical cystectomy (RC) or radiotherapy. 3,481 patients were included and divided into 4 groups: chemotherapy only, chemotherapy and RC, chemotherapy and radiation therapy, and chemotherapy, RC, and radiation therapy. Demographic data was compared using ANOVA for continuous variables, and Chi-square for categorical variables. Multivariable analysis was done to compare groups using a multinomial logistic regression model. Kaplan-Meier test was used for survival analysis and Cox-Regression was used for multivariable survival analysis. Results: Patients undergoing RC were significantly younger (P <0.001). There was a significant difference between the groups regarding racial distribution, facility-type and insurance status. There was no difference in gender, Charlson\Deyo score, financial or educational status. Patients who underwent combination therapy with chemotherapy and RC were found to have the longest median survival time at 27 months. Multivariable analysis showed that final treatment, age, sex, Charlson\Deyo comorbidity score, TNM edition and facility-type were significant survival predictors. Race, insurance and financial status failed to maintain significance. There was no survival difference between the chemotherapy group and chemo-radiotherapy group. Conclusions: The combination of surgery and chemotherapy achieves statistically significant superior survival in cN+ bladder cancer. Adding radiotherapy to chemotherapy did not improve survival in this group of patients. Abbreviations: (cN+): Clinically node-positive non-metastatic, (MIBC): Muscle invasive bladder cancer, (NCDB): National Cancer Database, (NAC): Neoadjuvant chemotherapy, (RC): Radical Cystectomy.

Bridging the Gap-Building Surgical Subspecialty Telemedicine Clinics in the Rural Setting.

INTRODUCTION: Pediatric urology is a much-needed subspecialty with a breadth of complex disorders that can often prove challenging to diagnose and manage. Exacerbating this need is the minimal exposure medical trainees receive to pediatric urology. Pediatric urology arrived in West Virginia in 1983 but the subspecialty has been inconsistently represented since then. Currently there are 2 fellowship-trained pediatric urologists in the state of West Virginia, which has an area of approximately 24,038 square miles. We review our experience with the use of telemedicine in providing outreach to the wider parts of our medically underserved state and ultimately evaluate its efficacy from a patient-centric cost analysis and diagnosis concordance perspective. We hypothesized that the use of telemedicine would be cost and time-effective for patients in our rural state. METHODS: We retrospectively reviewed our series of patients presenting from outside telemedicine "referral centers" in Martinsburg, Parkersburg and Wheeling for pediatric urological consultation. We evaluated reason for consultation, geographic driving distance, drive time and travel cost saved from telemedicine consultation. RESULTS: A total of 92 patients presented to outside designated telemedicine centers from August 2018 to April 2020. The mean driving time saved utilizing telemedicine consultation was 4 hours and 46 minutes, and mean driving distance saved was 299.8 miles. Travel costs saved in terms of fuel averaged $173.88 per patient. The most common reason for consultation was undescended testis, followed by recurrent urinary tract infection and nocturnal enuresis. Of the 23 patients who required surgery, only 2 (8.7%) had an initial diagnosis that was not concordant with their operating room examination. CONCLUSIONS: While modest, our data indicate a modern solution to a historical need in our state. Our high diagnosis concordance rate (91.3%) shows that a well-trained advanced practice provider can adequately perform an operative evaluation via telemedicine.

A Rare Case of Urinary Tract Fungal Ball Leading to Fungemia and Bilateral Chorioretinitis.

BACKGROUND: Fungemia due to obstructive urinary tract fungal ball is exceedingly rare. These patients often have multiple predisposing conditions, including diabetes or antimicrobial exposure. While candiduria can be relatively common in this population, urinary tract fungal balls are a rare entity. Hospitalists should be aware of this rare complication in patients presenting with funguria. Case Presentation. We present a case of a 44-year-old male with type II diabetes, chronic hepatitis C secondary to injection drug use, and chronic kidney disease who developed a urinary tract fungal ball leading to fungemia and subsequent bilateral chorioretinitis, additionally complicated by emphysematous cystitis and pyelonephritis. Additional invasive treatment options beyond typical antifungals are often required in the case of urinary tract fungal ball, and in this case, bilateral nephrostomy tubes and micafungin were employed. Hospital course was complicated by C. tropicalis fungemia with subsequent bilateral fungal chorioretinitis on dilated fundus exam. This was effectively treated with cyclogyl and prednisolone drops along with bilateral voriconazole injections. Follow-up imaging and cultures showed resolution of fungemia, urinary tract masses, and chorioretinal infiltrates; however, recurrent polymicrobial UTIs continue to be an issue for this patient. CONCLUSIONS: Special multidisciplinary management is required in the treatment of urinary tract fungal balls with subsequent fungemia, including nephrostomy tubes, antifungal irrigation, ureterorenoscopy, and more powerful antifungals such as amphotericin B and 5-flucytosine. This management draws from a myriad of specialties, including urology, infectious disease, and interventional radiology. Additionally, the literature has demonstrated that only approximately half of patients with fungemia receive an ophthalmologic evaluation. Ophthalmologic and urologic cooperation is essential in the case of obstructive uropathy leading to fungemia as the obstructive uropathy must be relieved and these patients should receive a dilated fundus exam.

Implications of Drug Use Disorders on Spine Surgery.

BACKGROUND: The opioid crisis has been declared a "public health emergency." Spine surgeons are treating more patients with substance use disorders (SUDs). OBJECTIVE: To investigate the outcomes of patients with SUD who undergo spine surgery. METHODS: A retrospective chart review was performed on patients with SUD who underwent nonelective spine surgery by orthopedic or neurosurgical staff from 2012 to 2017 at a level 1 trauma center and spine referral center. Three elective cases were excluded. RESULTS: A total of 49 patients undergoing 72 surgeries were reviewed. The most common substances of abuse were opioids (44/49 patients; 90%). Of 31 patients using multisubstances (63%), 29 misused opioids. The most common indications for surgery were infection (26/49, 53%), trauma (13/49, 27%), and myelopathy (7/49, 14%). Fusions (35/49, 71%) and irrigation and debridement surgeries (12/49, 24%) predominated. Twenty-nine percent (14/49) of patients had complications, the most common being hardware failure (7/49, 14%). Twenty percent (10/49) of patients left against medical advice and 22% (11/49) did not follow up after hospital discharge. The average length of hospital stay was 22 days. Forty-five percent (22/49) of patients were known to be in a drug program preoperatively versus 39% (19/49) postoperatively. Sixty-five percent (32/49) were prescribed opioids in the immediate postoperative period and 47% (23/49) continued to abuse drugs postoperatively. CONCLUSIONS: Patients with SUD are at increased risk of complications and inadequate follow-up. Additional studies are warranted to determine whether additional perioperative education, psychiatry consultations, or prescription of opioid addiction treatment regimens will improve drug use cessation and outcomes.

Validation of an extrinsic compression and early ambulation protocol after diagnostic transfemoral cerebral angiography: a 5-year prospective series.

BACKGROUND AND PURPOSE: Access-site complications constitute a substantial portion of the morbidity associated with transfemoral cerebral angiography, yet no standardized protocol exists for femoral closure and practice patterns vary widely. The objective of this single-arm prospective cohort study was to validate the efficacy and safety of a standardized femoral closure strategy for all diagnostic angiography, regardless of antiplatelet regimen. METHODS: A single-arm, prospective study was designed enrolling consecutive patients undergoing diagnostic transfemoral cerebral angiography by a single neurointerventional surgeon from March 2013 - March 2018. The closure protocol consisted of 20 minutes of manual compression to the site of arterial access and 2 hours of bedrest. The primary outcome was hematoma or oozing after manual compression. Demographic, clinic, and laboratory data were collected and analyzed, and patients were stratified by antiplatelet use. RESULTS: Of 525 angiograms, 263 (50.1%) were on patients taking antiplatelet medication, with 66 (12.6%) on dual antiplatelet regimens. Five patients (0.95% of all patients) met the primary outcome: in all five cases, there was no further oozing or enlarging hematoma after the additional compression period. There were not significant differences in primary outcome in groups stratified by antiplatelet use, and there were no instances of delayed hematoma, pseudoaneurysm, or arteriovenous fistula. CONCLUSION: In this single-arm cohort study of 525 consecutive transfemoral angiograms with a standardized extrinsic compression protocol, hemostasis was achieved without complication in >99% regardless of antiplatelet strategy. This protocol is effective and safe for diagnostic transfemoral angiography regardless of a patient's antiplatelet use.