The underrepresentation of racial/ethnic minorities in research on co-use of nicotine, alcohol, and/or cannabis via ecological momentary assessment methods: A narrative review.

BACKGROUND: Co-use of nicotine, alcohol and/or cannabis is common among adults in the United States. Co-use may represent greater addiction severity than single substance use. Recent studies have examined the extent to which the frequency, order, simultaneity, motivations, and contextual factors associated with co-use differ from that of single use. Co-use has become prevalent among racial/ethnic minority individuals who exhibit distinct co-use patterns and related outcomes; however, most of these studies rely on cross-sectional or sparse longitudinal observations. Ecological momentary assessment (EMA) can illuminate such patterns and associations with time-varying contexts. This review summarizes EMA studies on co-use published from 2008 to 2023 involving racial/ethnic minority individuals and point to gaps. Our review addresses: 1) whether use of one substance leads to substitution or complementary use of another, 2) whether antecedents/contexts differ by co-use patterns and minority status, and 3) what consequences of co-use have been documented across co-use patterns or minority status. METHODS: Search results yielded 465 articles, with 33 meeting inclusion criteria. We extracted study-level characteristics and synthesized the findings. RESULTS: The findings largely focused on co-use patterns, categories of co-use, proximal antecedents and contexts, and consequences. Variations by minority status were rarely examined; few examined acute effects of unique experiences that may contribute to co-use among racial/ethnic minority adults. CONCLUSIONS: The EMA literature on co-use is burgeoning in recent years and supports complementary hypothesis. More research to capture time-intensive data on experiences to contextualize the co-use among racial/ethnic minority groups with greater diversity in race/ethnicity is warranted.

Selective targeting and modulation of plaque associated microglia via systemic hydroxyl dendrimer administration in an Alzheimer's disease mouse model.

BACKGROUND: In Alzheimer's disease (AD), microglia surround extracellular plaques and mount a sustained inflammatory response, contributing to the pathogenesis of the disease. Identifying approaches to specifically target plaque-associated microglia (PAMs) without interfering in the homeostatic functions of non-plaque associated microglia would afford a powerful tool and potential therapeutic avenue. METHODS: Here, we demonstrated that a systemically administered nanomedicine, hydroxyl dendrimers (HDs), can cross the blood brain barrier and are preferentially taken up by PAMs in a mouse model of AD. As proof of principle, to demonstrate biological effects in PAM function, we treated the 5xFAD mouse model of amyloidosis for 4 weeks via systemic administration (ip, 2x weekly) of HDs conjugated to a colony stimulating factor-1 receptor (CSF1R) inhibitor (D-45113). RESULTS: Treatment resulted in significant reductions in amyloid-beta (Aß) and a stark reduction in the number of microglia and microglia-plaque association in the subiculum and somatosensory cortex, as well as a downregulation in microglial, inflammatory, and synaptic gene expression compared to vehicle treated 5xFAD mice. CONCLUSIONS: This study demonstrates that systemic administration of a dendranib may be utilized to target and modulate PAMs.

Clinical and socioeconomic predictors of shunt malfunction in the pediatric emergency department.

OBJECTIVE: The aim of this study was to delineate the clinical and socioeconomic variables associated with shunt revision in pediatric patients presenting to the emergency department (ED) with concerns of ventricular shunt malfunction. METHODS: A retrospective analysis of pediatric ED consultations for shunt malfunction over a 1-year period was conducted, examining clinical symptoms, radiographic findings, and socioeconomic variables. Sensitivities, specificities, and positive and negative predictive values were calculated for each presenting symptom collected. Logistic regression models were used to estimate the odds ratios for shunt revision based on these variables, and multivariate analyses were used to adjust for potential confounders. RESULTS: Of the 271 ED visits from 137 patients, 19.2% resulted in shunt revision. Increased ventricle size on imaging (OR 11.38, p < 0.001), shunt site swelling (OR 9.04, p = 0.01), bradycardia (OR 7.08, p < 0.001), and lethargy (OR 5.77, p < 0.001) were significantly associated with shunt revision. Seizure-like activity was inversely related to revision needs (OR 0.24, p < 0.001). Patients with private or self-pay insurance were more likely to undergo revision compared with those with public insurance (p = 0.028). Multivariate analysis further confirmed the significant associations of increased ventricle size, lethargy, and bradycardia with shunt revision, while also revealing that seizure-like activity inversely affected the likelihood of revision. Patients with severe cognitive and language disabilities were more likely to be admitted to the hospital from the ED but were not more likely to undergo revision. CONCLUSIONS: Clinical signs such as increased ventricle size, shunt site swelling, bradycardia, and lethargy may be strong predictors of the need for shunt revision in pediatric patients presenting to the ED with concerns of shunt malfunction. Socioeconomic factors play a less clear role in predicting shunt revision and admission from the ED; however, the nature of their influence is unclear. These findings can help inform clinical decision-making and optimize resource utilization in the ED.

A Systematic Review of Tear Vascular Endothelial Growth Factor and External Eye Diseases.

We aim to summarize the current evidence of Vascular endothelial growth factors (VEGF)s in external eye diseases and determine whether serum and plasma VEGF levels are associated with tear and ocular surface tissues. A systematic search of PUBMED and EMBASE was conducted using PRISMA guidelines between October 2022 and November 2023, with no restriction on language or publication date. Search terms included relevant MESH terms. These studies were evaluated for quality, and an assessment of the risk of bias was also carried out. Extracted data were then visually represented through relevant tables or figures. The initial literature search yielded 777 studies from PUBMED, 944 studies from EMBASE, and 10 studies from manual searches. Fourteen eligible studies were identified from 289 articles published from 2000 to 2023 in the English language or with English translations, including rabbit models, murine models, and human-derived samples. Most studies were retrospective in nature and case-control studies. Various common external eye diseases, such as dry eye disease (DED) and allergic eye disease were investigated. Despite limitations and small sample sizes, researchers have found elevated tissue levels of the VEGF in the vascularized cornea, especially in animal models, but there is no evidence of clear changes in the tear concentrations of VEGF in DED and allergic eye disease. Tear VEGF is associated with corneal vascularization. Anti-VEGF therapies may have the potential to manage such conditions.

The Shunt Valve Recession Technique as a Neuroplastic Surgery Adjunct in Complex and High-Risk Shunt Revisions: Technical Note and Case Series.

BACKGROUND AND OBJECTIVES: Ventricular shunting is one of the most common procedures in neurosurgery. However, complications and revisions are frequent. Patients requiring multiple revisions often suffer secondary issues with scalp healing over hardware. Many common ventricular shunt valves have an obligate thickness that creates a visible protrusion and can potentially cause local tissue ischemia and breakdown in the setting of repeated surgery. The authors present a simple technique for recessing the shunt valve into the underlying bone to alleviate protrusion in high-risk cases. Three example cases utilizing this technique are presented. METHODS: The skull directly underlying the planned valve site is uniformly recessed with a cutting burr several millimeters as desired while maintaining the inner cortical bone layer. The valve is fixed with standard cranial plating hardware. EXPECTED OUTCOMES: Three patients are reported who underwent shunt valve recession as an adjunct to their shunt revision with neuroplastic surgery assistance. All patients had undergone multiple prior surgeries that had resulted in thin and high-risk fragile scalp. In 1 patient, the prior valve was eroding through the scalp before the described revision. All patients had satisfactory cosmetic outcomes, and there were no revisions in the 2-month follow-up period. DISCUSSION: Complex and high-risk ventricular shunt patients should be considered for shunt valve recession into the bone to reduce wound-related complications and enhance healing. This is a technically simple, safe, and effective technique to include as a neuroplastic adjunct.

Large variation in radiation dose for routine abdomen CT: reasons for excess and easy tips for reduction.

OBJECTIVE: To characterize the use and impact of radiation dose reduction techniques in actual practice for routine abdomen CT. METHODS: We retrospectively analyzed consecutive routine abdomen CT scans in adults from a large dose registry, contributed by 95 hospitals and imaging facilities. Grouping exams into deciles by, first, patient size, and second, size-adjusted dose length product (DLP), we summarized dose and technical parameters and estimated which parameters contributed most to between-protocols dose variation. Lastly, we modeled the total population dose if all protocols with mean size-adjusted DLP above 433 or 645 mGy-cm were reduced to these thresholds. RESULTS: A total of 748,846 CTs were performed using 1033 unique protocols. When sorted by patient size, patients with larger abdominal diameters had increased dose and effective mAs (milliampere seconds), even after adjusting for patient size. When sorted by size-adjusted dose, patients in the highest versus the lowest decile in size-adjusted DLP received 6.4 times the average dose (1680 vs 265 mGy-cm) even though diameter was no different (312 vs 309 mm). Effective mAs was 2.1-fold higher, unadjusted CTDIvol 2.9-fold, and phase 2.5-fold for patients in the highest versus lowest size-adjusted DLP decile. There was virtually no change in kV (kilovolt). Automatic exposure control was widely used to modulate mAs, whereas kV modulation was rare. Phase was the strongest driver of between-protocols variation. Broad adoption of optimized protocols could result in total population dose reductions of 18.6-40%. CONCLUSION: There are large variations in radiation doses for routine abdomen CT unrelated to patient size. Modification of kV and single-phase scanning could result in substantial dose reduction. CLINICAL RELEVANCE: Radiation dose-optimization techniques for routine abdomen CT are routinely under-utilized leading to higher doses than needed. Greater modification of technical parameters and number of phases could result in substantial reduction in radiation exposure to patients. KEY POINTS: • Based on an analysis of 748,846 routine abdomen CT scans in adults, radiation doses varied tremendously across patients of the same size and optimization techniques were routinely under-utilized. • The difference in observed dose was due to variation in technical parameters and phase count. Automatic exposure control was commonly used to modify effective mAs, whereas kV was rarely adjusted for patient size. Routine abdomen CT should be performed using a single phase, yet multi-phase was common. • kV modulation by patient size and restriction to a single phase for routine abdomen indications could result in substantial reduction in radiation doses using well-established dose optimization approaches.

Next Level of Care Protocols in Radiology: Improving Patient Access to Care.

OBJECTIVE: To introduce a novel next level of care (NLC) protocol used in our breast imaging practice to bypass additional imaging and image-guided biopsy orders and to examine the impact of NLC on breast biopsy wait times compared with thyroid biopsy wait times, which do not use NLC. METHODS: Our institutional review board deemed this retrospective analysis to be exempt. NLC was implemented for breast imaging in late 2014. Two 6-month periods before and after the COVID-19 shutdown were sampled and compiled. Data were queried from departmental database and electronic health record for all breast and thyroid biopsies during this time. Time to biopsy (TTB) was defined as the number of days from the diagnostic imaging evaluation recommending the biopsy to the completion of the biopsy. To determine the effect of NLC, TTB was compared between breast and thyroid biopsies. RESULTS: Of the 1,114 breast biopsies and 154 thyroid biopsies included, the mean TTB was 9 days (95% confidence interval 8.4-9.3) for breast and 23 days (95% confidence interval 20.5-25.0) for thyroid. There was a 61% reduction in the mean TTB for patients in the breast group compared with patients in the thyroid group. The effect of the NLC was comparable among different races and ethnicities in the breast group, but a significantly higher mean TTB (24% higher, P = .025) was observed for thyroid biopsies in Black patients compared with thyroid biopsies in Hispanic patients. CONCLUSION: NLC protocol facilitates imaging evaluations and reduces the time interval to image-guided biopsies.

Proximity to Cannabis Retailers and Recent Cannabis Use among a Diverse Sample of California Adolescents.

Background: As of May 2023, 23 states and Washington, DC have legalized the sale of cannabis for adults aged 21+, and 38 states, three territories, and D.C. have legalized medical cannabis. Exposure to cannabis retailers could increase adolescent cannabis use. Few studies have examined the impact of residential proximity to cannabis retailers on adolescent cannabis use, and previous findings are inconsistent. Methods: This study examined associations between proximity to cannabis retailers and past 30-day cannabis use. Data were from Project Cal Teens, a statewide survey of California adolescents regarding cannabis-related opinions/behaviors (N = 1406, mean age = 15.5 years, 48% female, 38% Hispanic/Latinx, 33% White, 15% Asian/Pacific Islander, 10% Black/African American, 5% Other/Multiracial). Participants were recruited via schools/social media in 2018-2020. Results: For every additional 5 driving miles to the nearest cannabis retailer, the risk of past 30-day cannabis use was reduced by 3.6% [IRR: 0.964; 95% CI: 0.935-0.994]. For every additional 5 miles from a licensed retailer, the risk of past 30-day cannabis use was reduced by 4.3% [IRR: 0.957; 95% CI: 0.926-0.989]. Interaction analyses revealed that among Hispanic/Latinx students, every 5 miles from a licensed retailer was associated with an 11.9% reduction in the risk of past 30-day cannabis use [IRR: 0.881; 95% CI: 0.820-0.945]. Conclusions: As the number of cannabis retailers in the U.S. increases with the continued legalization of adult cannabis use, research examining the effects of these policies on underage use is crucial. Interventions could include enforcement of zoning laws in/near residential areas to reduce accessibility of adolescents to cannabis retailers.

Functional recovery in a cohort of ECMO and non-ECMO acute respiratory distress syndrome survivors.

BACKGROUND: The mortality benefit of VV-ECMO in ARDS has been extensively studied, but the impact on long-term functional outcomes of survivors is poorly defined. We aimed to assess the association between ECMO and functional outcomes in a contemporaneous cohort of survivors of ARDS. METHODS: Multicenter retrospective cohort study of ARDS survivors who presented to follow-up clinic. The primary outcome was FVC% predicted. Univariate and multivariate regression models were used to evaluate the impact of ECMO on the primary outcome. RESULTS: This study enrolled 110 survivors of ARDS, 34 of whom were managed using ECMO. The ECMO cohort was younger (35 [28, 50] vs. 51 [44, 61] years old, p < 0.01), less likely to have COVID-19 (58% vs. 96%, p < 0.01), more severely ill based on the Sequential Organ Failure Assessment (SOFA) score (7 [5, 9] vs. 4 [3, 6], p < 0.01), dynamic lung compliance (15 mL/cmH20 [11, 20] vs. 27 mL/cmH20 [23, 35], p < 0.01), oxygenation index (26 [22, 33] vs. 9 [6, 11], p < 0.01), and their need for rescue modes of ventilation. ECMO patients had significantly longer lengths of hospitalization (46 [27, 62] vs. 16 [12, 31] days, p < 0.01) ICU stay (29 [19, 43] vs. 10 [5, 17] days, p < 0.01), and duration of mechanical ventilation (24 [14, 42] vs. 10 [7, 17] days, p < 0.01). Functional outcomes were similar in ECMO and non-ECMO patients. ECMO did not predict changes in lung function when adjusting for age, SOFA, COVID-19 status, or length of hospitalization. CONCLUSIONS: There were no significant differences in the FVC% predicted, or other markers of pulmonary, neurocognitive, or psychiatric functional recovery outcomes, when comparing a contemporaneous clinic-based cohort of survivors of ARDS managed with ECMO to those without ECMO.

Establishing proof of concept for sonolucent cranioplasty and point of care ultrasound imaging after posterior fossa decompression for Chiari malformation.

BACKGROUND: Evaluation after posterior fossa decompression for Chiari malformation can require repeated imaging, particularly with persistent symptoms. Typically, CT or MRI is used. However, CT carries radiation risk and MRI is costly. Ultrasound is an inexpensive, radiation-free, point-of-care modality that has, thus far, been limited by intact skull and traditional cranioplasty materials. Ultrasound also allows for imaging in different head positions and body postures, which may lend insight into cause for persistent symptoms despite adequate decompression on traditional neutral static CT or MRI. We evaluate safety and feasibility of ultrasound as a post-operative imaging modality in patients reconstructed with sonolucent cranioplasty during posterior fossa decompression for Chiari malformation. METHODS: Outcomes were analyzed for 26 consecutive patients treated with a Chiari-specific sonolucent cranioplasty. This included infection, need for revision, CSF leak, and pseudomeningocele. Ultrasound was performed point-of-care in the outpatient clinic by the neurosurgery team to assess feasibility. RESULTS: In eight months mean follow up, there were no surgical site infections or revisions with this novel sonolucent cranioplasty. Posterior fossa anatomy was discernable via transcutaneous ultrasound obtained point-of-care in the clinic setting at follow up visits. CONCLUSION: We demonstrate proof of concept for ultrasound as a post-operative imaging modality after posterior fossa decompression for Chiari malformation. With further investigation, ultrasound may prove to serve as an alternative to CT and MRI in this patient population, or as an adjunct to provide positional and dynamic information. Use of sonolucent cranioplasty is safe. This technique deserves further study.

Methods of Machine Learning-Based Chimeric Antigen Receptor Immunological Synapse Quality Quantification.

Chimeric Antigen Receptor (CAR)-mediated immunotherapy shows promising results for refractory blood cancers. Currently, six CAR-T drugs have been approved by U.S. Food and Drug Administration (FDA). Theoretically, CAR-T cells must form an effective immunological synapse (IS, an interface between effective cells and their target cells) with their susceptible tumor cells to eliminate tumor cells. Previous studies show that CAR IS quality can be used as a predictive functional biomarker for CAR-T immunotherapies. However, quantification of CAR-T IS quality is clinically challenging. Machine learning (ML)-based CAR-T IS quality quantification has been proposed previously.Here, we show an easy-to-use, step-by-step approach to predicting the efficacy of CAR-modified cells using ML-based CAR IS quality quantification. This approach will guide the users on how to use ML-based CAR IS quality quantification in detail, which include: how to image CAR IS on the glass-supported planar lipid bilayer, how to define the CAR IS focal plane, how to segment the CAR IS images, and how to quantify the IS quality using ML-based algorithms.This approach will significantly enhance the accuracy and proficiency of CAR IS prediction in research.

Spinal dysraphism in exstrophy: a single-center study of a 39-year prospective database.

OBJECTIVE: The two main objectives of this study were to explore the rate of spinal dysraphism within bladder and cloacal exstrophy and to analyze the relationship between spinal dysraphism surgery, including timing of spinal dysraphism surgery, with urological and neurological outcomes. METHODS: A prospectively maintained IRB-approved database of pediatric exstrophy patients treated from 1982 to 2021 was retrospectively reviewed for patients with spinal dysraphism. Spinal dysraphism was categorized into the following 7 subtypes: lipoma-based closed defect, myelomeningocele, meningocele, diastematomyelia, myelocystocele, low-lying conus with tethered cord/fatty filum, and sacral bony defect. Other factors assessed included patient demographic characteristics, type of spinal dysraphism procedure, reoperation, complication, presence of other neurological problems (e.g., hydrocephalus, Chiari malformation), neurological status, and urological function. RESULTS: Analysis revealed that 114/1401 patients had coexisting spinal dysraphism. Of these 114, sufficient records including type of dysraphism were available for 54. Spinal dysraphism was most common within cloacal exstrophy (83.3% [45/54 patients]), followed by cloacal exstrophy variants (9.3% [5/54]), classic bladder exstrophy (3.7% [2/54]), and classic bladder exstrophy variants (3.7% [2/54]). Within spinal dysraphism, lipoma-based closed defects (63.0% [34/54]) and low-lying conus with tethered cord/fatty filum (11.1% [6/54]) were most common. Hydrocephalus and Chiari malformation occurred in 24.1% (13/54) and 11.1% (6/54) of patients. All 13 patients with hydrocephalus underwent shunt placement. Among those who underwent neurosurgical intervention, the complication rate for spinal dysraphism was 14.6% (7/48). Motor function data were available for 41 patients and revealed that motor function declined for 2/41 (4.8%) patients and improved for 6/41 (14.6%) after neurosurgery. There was no statistical difference in lower-extremity motor outcome related to timing of neurosurgery and exstrophy closure. CONCLUSIONS: The authors have reported the surgical management and outcomes of patients with exstrophy and coexisting spinal dysraphism (n = 54). In 54 patients, spinal dysraphism was most common in the subset of patients with cloacal exstrophy (83.3%). Lipoma-based closed defects (63.0%) and low-lying conus with tethered cord/fatty filum (11.1%) were the most common, and the rates of hydrocephalus and Chiari malformation were 24.1% and 11.1%, respectively. There was no difference in lower-extremity motor outcome related to timing of neurosurgery and exstrophy closure.

Pandemic-related life changes and adolescent initiation of cannabis and tobacco/nicotine use.

BACKGROUND: The COVID-19 pandemic required the public to alter their daily lives drastically. For adolescents, school closures and social isolation added further challenges to a stressful stage of life, potentially increasing the likelihood of substance use initiation. This study explored the relationship between adolescent substance use initiation and negative life changes due to COVID-19. METHODS: Students from 9 high schools (N = 2478) in Los Angeles County were surveyed as 9th graders in the 2019-2020 school year and re-surveyed in 10th and 11th grades as part of an ongoing longitudinal study. Two logistic regression models were conducted to test hypotheses that negative life changes due to the COVID-19 pandemic increases the odds of initiation of both tobacco/nicotine products and cannabis products, controlling for sex, age, and race/ethnicity. RESULTS: The final analytic sample included adolescents in 10th grade who were never-users of tobacco/nicotine (N = 809) and cannabis (N = 837). The odds of initiating cannabis use increased by 6.42% for every 1 standard deviation increase in the COVID-19 negative daily life changes index [AOR: 1.063; 95% CI: 1.010, 1.121]. The association between the COVID-19 negative daily life changes index and tobacco/nicotine use initiation was not significant. DISCUSSION: Adolescents who experienced life changes due to COVID-19 were more likely to initiate cannabis use, but not tobacco/nicotine use. Results identify a need for early intervention efforts to promote effective coping skills and prevent cannabis initiation among adolescents during a wide-scale stressor, such as COVID-19.

Implication of American Society of Anesthesiologists Physical Status (ASA-PS) on tonsillectomy with or without adenoidectomy outcomes.

BACKGROUND: The American Society of Anesthesiologists Physical status classification (ASA-PS) is a simple categorization of a patient's physiological status during the perioperative period. The role of ASA-PS in predicting operative risk and complications following tonsillectomy with or without adenoidectomy (T ± A) has not been studied. The objective of the study was to identify the association of the pre-operative ASA-PS with 30-day complication rates and adverse events following T ± A. STUDY DESIGN: A retrospective analysis was performed using data from the American College of Surgeons' National Surgical Quality Improvement Program database (ACS NSQIP) of patients aged 16 years or older who underwent T ± A between 2005 and 2016. Patients were stratified into ASA-PS Classes I/II and III/IV. Patient demographics, preoperative comorbidities, pre-operative laboratory values, operation-specific variables, and postoperative outcomes in the 30-day period following surgery were compared between the two subsets of ASA-PS groups. RESULTS: On multivariate analysis, patients with ASA class III and IV were more likely to experience an unplanned readmission (OR 1.39, 95 % CI 1.09-1.76; p = 0.007), overall complications (OR 1.49, 95 % CI 1.28-1.72; p < 0.001), major complications (OR 1.52, 95 % CI 1.31-1.77, p ≤ 0.001), reoperation (OR 1.33, 95 % CI 1.04-1.69; p = 0.022), and extended length of stay >1 day (OR 1.78, 95 % CI 1.41-2.25; p < 0.001) following a T ± A. CONCLUSION: Higher ASA-PS classification is an independent predictor of complications following T ± A. Surgeons should aim to optimize the systemic medical conditions of ASA-PS classes III and IV patients prior to T ± A and implement post-operative management protocols specific to these patients to decrease morbidity, complications, and overall health care cost.

Preoperative cross-sectional area of psoas muscle correlates with short-term functional outcomes after posterior lumbar surgery.

PURPOSE: To determine the optimal level for the measurement of psoas cross-sectional area and examine the correlation with short-term functional outcomes of posterior lumbar surgery. METHODS: Patients who underwent minimally invasive posterior lumbar surgery were included in this study. The cross-sectional area of psoas muscle was measured at each intervertebral level on T2-weighted axial images of preoperative MRI. Normalized total psoas area (NTPA) (mm2/m2) was calculated as total psoas area normalized to patient height. Intraclass Correlation Coefficient (ICC) was calculated for the analysis of inter-rater reliability. Patient reported outcome measures including Oswestry disability index (ODI), visual analog scale (VAS), short form health survey (SF-12) and patient-reported outcomes measurement information system were collected. A multivariate analysis was performed to elucidate independent predictors associated with failure to reach minimal clinically important difference (MCID) in each functional outcome at 6 months. RESULTS: The total of 212 patients were included in this study. ICC was highest at L3/4 [0.992 (95% CI: 0.987-0.994)] compared to the other levels [L1/2 0.983 (0.973-0.989), L2/3 0.991 (0.986-0.994), L4/5 0.928 (0.893-0.952)]. Postoperative PROMs were significantly worse in patients with low NTPA. Low NTPA was an independent predictor of failure to reach MCID in ODI (OR = 2.68; 95% CI: 1.26-5.67; p = 0.010) and VAS leg (OR = 2.43; 95% CI: 1.13-5.20; p = 0.022). CONCLUSION: Decreased psoas cross-sectional area on preoperative MRI correlated with functional outcomes after posterior lumbar surgery. NTPA was highly reliable, especially at L3/4.

Surgery or Endovascular Treatment in Patients with Anterior Communicating Artery Aneurysm: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVE: Although randomized controlled trials have compared surgery versus endovascular treatment for intracranial aneurysms, the literature is sparse in terms of subgroup analysis for anterior communicating artery (ACoA) aneurysm management. This systematic review and meta-analysis sought to compare surgical versus endovascular treatment for ACoA aneurysms. METHODS: Medline, PubMed, and Embase were searched from inception to December 12, 2022. Primary outcomes were post-treatment modified Rankin Scale (mRS) >2 and mortality. Secondary outcomes were aneurysm obliteration, retreatment and recurrence, rebleeding, technical failure, vessel rupture, aneurysmal subarachnoid hemorrhage-related hydrocephalus, symptomatic vasospasm, and stroke. RESULTS: Eighteen studies yielded 2368 patients, from which 1196 (50.5%) and 1172 (49.4%) patients underwent surgery and endovascular treatment, respectively. The odds ratio (OR) of mortality was similar in total (OR = 0.92 [0.63-1.37], P = 0.69), ruptured (OR = 0.92 [0.62-1.36], P = 0.66), and unruptured cohorts (OR = 1.58 [0.06-39.60], P = 0.78). The OR of mRS > 2 was similar in total (OR = 0.75 [0.50-1.13], P = 0.17), ruptured (OR = 0.77 [0.49-1.20], P = 0.25), and unruptured cohorts (OR = 0.64 [0.21-1.96], P = 0.44). The OR of obliteration was higher with surgery in the total (OR = 2.52 [1.49-4.27], P = 0.0008) and ruptured cohorts (OR = 2.61 [1.33-5.10], P = 0.005) and unruptured group (OR = 3.46 [1.30-9.20], P = 0.01). The OR of retreatment was lower with surgery in the total (OR = 0.37 [0.17-0.76], P = 0.007) and ruptured cohorts (OR = 0.31 [0.11-0.89], P = 0.03), thought it was similar in the unruptured group (OR = 0.51 [0.08-3.03], P = 0.46). The OR of recurrence was lower with surgery in the total (OR = 0.22 [0.10, 0.47], P = 0.0001), ruptured (OR = 0.16 [0.03, 0.90], P = 0.04), and mixed (un) ruptured cohorts (OR = 0.22 [0.09-0.53], P = 0.0009). The OR of rebleeding in ruptured group was similar (OR = 0.66 [0.29-1.52], P = 0.33). The ORs of other outcomes were similar. CONCLUSIONS: ACoA aneurysms may be safely treated with either surgery or endovascular treatment, although microsurgical clipping demonstrates higher obliteration rates and lower rates of retreatment and recurrence.

Microsurgery Versus Stereotactic Radiosurgery for Treatment of Patients With Brain Arteriovenous Malformation: A Systematic Review and Meta-Analysis.

BACKGROUND: Treatment decision-making for brain arteriovenous malformations (bAVMs) with microsurgery or stereotactic radiosurgery (SRS) is controversial. OBJECTIVE: To conduct a systematic review and meta-analysis to compare microsurgery vs SRS for bAVMs. METHOD: Medline and PubMed were searched from inception to June 21, 2022. The primary outcomes were obliteration and follow-up hemorrhage, and secondary outcomes were permanent neurological deficit, worsened modified Rankin scale (mRS), follow-up mRS > 2, and mortality. The GRADE approach was used for grading the level of evidence. RESULTS: Eight studies were included, which yielded 817 patients, of which 432 (52.8%) and 385 (47.1%) patients underwent microsurgery and SRS, respectively. Two cohorts were comparable in age, sex, Spetzler-Martin grade, nidus size, location, deep venous drainage, eloquence, and follow-up. In the microsurgery group, the odds ratio (OR) of obliteration was higher (OR = 18.51 [11.05, 31.01], P < .000001, evidence: high) and the hazard ratio of follow-up hemorrhage was lower (hazard ratio = 0.47 [0.23, 0.97], P = .04, evidence: moderate). The OR of permanent neurological deficit was higher with microsurgery (OR = 2.85 [1.63, 4.97], P = .0002, evidence: low), whereas the OR of worsened mRS (OR = 1.24 [0.65, 2.38], P = .52, evidence: moderate), follow-up mRS > 2 (OR = 0.78 [0.36, 1.7], P = .53, evidence: moderate), and mortality (OR = 1.17 [0.41, 3.3], P = .77, evidence: moderate) were comparable between the groups. CONCLUSION: Microsurgery was superior at obliterating bAVMs and preventing further hemorrhage. Despite a higher rate of postoperative neurological deficit with microsurgery, functional status and mortality were comparable with patients who underwent SRS. Microsurgery should remain a first-line consideration for bAVMs, with SRS reserved for inaccessible locations, highly eloquent areas, and medically high-risk or unwilling patients.

A Presentation of Synchronous Ovarian and Endometrial Endometrioid Adenocarcinoma From a Case of Suspected Ruptured Ectopic Pregnancy.

A 32-year-old woman of child-bearing age who initially underwent surgical laparoscopy for suspected ruptured ectopic pregnancy with elevated serum ß-human chorionic gonadotropin (hCG) levels was unexpectedly found to have histologically diagnosed synchronous ovarian and endometrial endometrioid adenocarcinoma. She subsequently underwent another full completion staging surgery and adjuvant chemotherapy as she was unsuitable for fertility-sparing surgery. An elevated serum ß-hCG level accompanied by clinical signs of acute abdominal pain, per vaginal bleeding, ultrasound features of abdominal free fluid in the pelvis and an adnexal mass warrants a high clinical suspicion for a ruptured ectopic pregnancy. However, it is important to recognize ovarian malignancy as a rare but differential diagnosis to suspected ectopic pregnancy in patients with acute abdomen. Fertility-sparing surgery may be considered for young patients seeking fertility, without compromising patient survival in women without synchronous gynecological cancers.

Validation of the Prognostic Usefulness of the Gene Expression Profiling Test in Patients with Uveal Melanoma.

PURPOSE: To validate the prognostic usefulness of gene expression profile (GEP) testing in patients with uveal melanoma. To determine whether combining tumor size with the GEP classification provides additional prognostic value. DESIGN: Retrospective analysis. PARTICIPANTS: Patients with a diagnosis of choroidal melanoma examined at Yale New Haven Hospital; University of California, San Diego; and Memorial Sloan Kettering Cancer Center. METHODS: Patients' demographic and clinical data and tumor characteristics were collected. Univariate and multivariate Cox hazard regression analysis were used to assess the association between tumor characteristics and GEP classification with metastasis as an outcome. MAIN OUTCOME MEASURES: Metastasis-free survival (MFS). RESULTS: Of the 337 individuals included in the study, 87 demonstrated metastases. The mean follow-up time was 37.2 (standard deviation [SD], 40.2) months for patients with metastases and 55.0 (SD, 49.3) months for those without metastases. Tumors of larger thickness and GEP class 2 (vs. class 1) were associated significantly with increased risk of metastasis. Tumor thickness showed better prognostic usefulness than GEP classification (Wald statistic, 40.7 and 24.2, respectively). Class 2 tumors with a thickness of 7.0 mm or more were associated with increased risk of metastasis than tumors with a thickness of < 7.0 mm (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.61-6.51), whereas class 1 tumors with a thickness of 9.0 mm or more were associated with increased risk of metastasis than tumors with a thickness of < 9.0 mm (HR, 2.07; 95% CI, 0.86-4.99). No difference in MFS was found between patients with class 1A tumors compared with those with class 1B tumors (P = 0.8). Patients with class 2 tumors showed an observed 5-year MFS of 47.5% (95% CI, 36.0%-62.8%). CONCLUSIONS: Tumor size was the most significant predictor of metastasis and provided additional prognostic value independent of GEP classification. In addition, rates of metastasis for class 2 tumors were lower than estimates reported by Castle Bioscience, and no difference in rates of metastasis were found between class 1A and 1B tumors. This indicates that tumor size should be accounted for when relying on GEP for prognostication and that patients with GEP class 1A or 1B tumors may benefit from the same metastatic surveillance protocols. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

First Experience With Postoperative Transcranial Ultrasound Through Sonolucent Burr Hole Covers in Adult Hydrocephalus Patients.

BACKGROUND: Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull. OBJECTIVE: To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients. METHODS: Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy. RESULTS: Thirty-seven patients with sonolucent burr hole cover were compared with 57 historical control patients. There was no statistically significant difference in infection rates between the sonolucent burr hole cover group (1/37, 2.7%) and the control group (0/57, P = .394). Revision rates were 13.5% vs 15.8% (P = 1.000), but no revisions were related to the burr hole or cranial hardware. CONCLUSION: Trans-burr hole ultrasound is feasible for gross evaluation of ventricular caliber postoperatively in patients with sonolucent burr hole covers. There was no increase in infection rate or revision rate. This imaging technique may serve as an alternative to CT and MRI in the management of select patients with hydrocephalus and CSF disorders.