Pain Outcomes Following Endoscopic Microvascular Decompression for Trigeminal Neuralgia Based on Vascular Compression Type.

Background Arterial compression of the trigeminal nerve at the root entry zone has been the long-attributed cause of compressive trigeminal neuralgia despite numerous studies reporting distal and/or venous compression. The impact of compression type on patient outcomes has not been fully elucidated. Objective We categorized vascular compression (VC) based on vessel and location of compression to correlate pain outcomes based on compression type. Methods A retrospective video review of 217 patients undergoing endoscopic microvascular decompression for trigeminal neuralgia categorizing VC into five distinct types, proximal arterial compression (VC1), proximal venous compression (VC2), distal arterial compression (VC3), distal venous compression (VC4), and no VC (VC5). VC type was correlated with postoperative pain outcomes at 1 month ( n = 179) and last follow-up (mean = 42.9 mo, n = 134). Results At 1 month and longest follow-up, respectively, pain was rated as "much improved" or "very much improved" in 89 69% of patients with VC1, 86.6 and 62.5% of patients with VC2, 100 and 87.5% of patients with VC3, 83 and 62.5% of patients with VC4, and 100 and 100% of patients with VC5. Multivariate analysis demonstrated VC4 as a significant negative of predictor pain outcomes at 1 month, but not longest follow-up, and advanced age as a significant positive predictor. Conclusion The degree of clinical improvement in all types of VC was excellent, but at longest follow-up VC type was not a significant predictor out outcome. However distal venous compression was significantly associated with worse outcomes at 1 month.

Enlarging and shrinking focal perivascular spaces.

BACKGROUND AND PURPOSE: Perivascular spaces (PVS) are interstitial fluid-filled spaces surrounding blood vessels traversing the deep gray nuclei and white matter of the brain. These are commonly encountered on CT and MR imaging and are generally asymptomatic and of no clinical significance. However, occasional changes in the size of focal PVS, for example, when enlarging, may mimic pathologies including neoplasms and infections, hence potentially confounding radiological interpretation. Given these potential diagnostic issues, we sought to better characterize common clinical and imaging features of focal PVS demonstrating size fluctuations. MATERIALS AND METHODS: Upon institutional approval, we retrospectively identified 4 cases demonstrating PVS with size changes at our institution. To supplement our cases, we also performed a literature review, which identified an additional 14 cases. Their clinical and imaging data were analyzed to identify characteristic features. RESULTS: Of the 18 total cases (including the 4 institutional cases), 10 cases increased and 8 decreased in size. These focal PVS ranged from 0.4-4.5 cm in size. Whereas a decrease in size did not represent a diagnostic issue, focal increase in size of PVS led to concerning differential diagnoses in at least 30% of the radiology reports. These enlarging PVS were most found in the basal ganglia and temporal lobe, and in patients with previous brain radiation treatment. CONCLUSION: Focal size change of PVS can occur, especially years after brain radiation treatment. Being cognizant of this benign finding is important to consider in the differential diagnosis to avoid undue patient anxiety or unnecessary medical intervention.

Managing incisional wounds with Prevena VAC therapy in lower-extremity vascular surgery: A comparative study.

BACKGROUND: Vascular surgical site infections have been reported with an overall incidence of 5-10% for patients undergoing arterial interventions and as high as 10-20% for lower-limb bypass grafting procedures. Given that vascular surgery patients are known to be at a higher risk of postoperative wound infections and other complications, our objective was to evaluate a potential method to reduce such complications. This study compares the rate of wound healing complications between incisional negative pressure wound therapy (NPWT) and conventional dressings in vascular surgery patients with infra-inguinal incisions. The primary endpoint is complete closure of the wound at the 2-week follow-up appointment. Secondary endpoints include frequency infections requiring antibiotics, need for wound revision, and wound dehiscence. METHODS: A prospective cohort study with retrospective control group was performed following infra-inguinal vascular surgeries for peripheral arterial disease at the Mount Carmel Health System. The patients included in this study were those who underwent a lower-extremity vascular procedure with primary closure of an incision distal to the groin between January 2014 and July 2018. Patients that had received an infra-inguinal incision with primary closure were included. Patients in the experimental group who had a Prevena Wound VAC were compared with a retrospectively obtained control arm treated with conventional dressings. Data regarding wound healing and complications, specifically infections and wound dehiscence, were obtained. RESULTS: A total of 201 patients were recruited in our study: 64 in the Prevena group and 137 in the control group. There was a significant reduction in the number of open wounds in the Prevena group compared to the control group at the 2-week follow-up (10.9% Prevena vs 33.6% control; p = .0005). When evaluated in aggregate, there was a statistically significant reduction in the number of patients who succumbed to any complication in the Prevena arm compared with traditional dressings (13 (20.3%) Prevena vs 72 (52.6%) control; p < .0001). CONCLUSION: The results of our study suggest there should be a significant consideration for the use of NPWT as a prophylactic measure to reduce the risk of wound complications of primarily closed infra-inguinal incisions in vascular surgery patients following common vascular procedures. Its use is particularly effective for patients at enhanced risk of infection, especially those with poor vascularization from BMI, smoking, and diabetes. This leads to decreased trends in antibiotic use, ED visits, readmissions, and surgical revisions, which translates to decreased utilization of hospital resources and economic burden.

The relevance of biologically effective dose for pain relief and sensory dysfunction after Gamma Knife radiosurgery for trigeminal neuralgia: an 871-patient multicenter study.

OBJECTIVE: Recent studies have suggested that biologically effective dose (BED) is an important correlate of pain relief and sensory dysfunction after Gamma Knife radiosurgery (GKRS) for trigeminal neuralgia (TN). The goal of this study was to determine if BED is superior to prescription dose in predicting outcomes in TN patients undergoing GKRS as a first procedure. METHODS: This was a retrospective study of 871 patients with type 1 TN from 13 GKRS centers. Patient demographics, pain characteristics, treatment parameters, and outcomes were reviewed. BED was compared with prescription dose and other dosimetric factors for their predictive value. RESULTS: The median age of the patients was 68 years, and 60% were female. Nearly 70% of patients experienced pain in the V2 and/or V3 dermatomes, predominantly on the right side (60%). Most patients had modified BNI Pain Intensity Scale grade IV or V pain (89.2%) and were taking 1 or 2 pain medications (74.1%). The median prescription dose was 80 Gy (range 62.5-95 Gy). The proximal trigeminal nerve was targeted in 77.9% of cases, and the median follow-up was 21 months (range 6-156 months). Initial pain relief (modified BNI Pain Intensity Scale grades I-IIIa) was noted in 81.8% of evaluable patients at a median of 30 days. Of 709 patients who achieved initial pain relief, 42.3% experienced at least one pain recurrence after GKRS at a median of 44 months, with 49.0% of these patients undergoing a second procedure. New-onset facial numbness occurred in 25.3% of patients after a median of 8 months. Age ≥ 63 years was associated with a higher probability of both initial pain relief and maintaining pain relief. A distal target location was associated with a higher probability of initial and long-term pain relief, but also a higher incidence of sensory dysfunction. BED ≥ 2100 Gy2.47 was predictive of pain relief at 30 days and 1 year for the distal target, whereas physical dose ≥ 85 Gy was significant for the proximal target, but the restricted range of BED values in this subgroup could be a confounding factor. A maximum brainstem point dose ≥ 29.5 Gy was associated with a higher probability of bothersome facial numbness. CONCLUSIONS: BED and physical dose were both predictive of pain relief and could be used as treatment planning goals for distal and proximal targets, respectively, while considering maximum brainstem point dose < 29.5 Gy as a potential constraint for bothersome numbness.

Multitarget deep brain stimulation for epilepsy.

OBJECTIVE: Deep brain stimulation (DBS) is a rapidly growing surgical option for patients with drug-resistant epilepsy who are not candidates for resective/ablative surgery. Recent randomized controlled trials have demonstrated efficacy of DBS of the anterior nucleus of the thalamus (ANT), particularly in frontal or temporal epilepsy, whereas DBS of the centromedian (CM) nucleus appears to be most suitable in well-defined generalized epilepsy syndromes. At the authors' institution, DBS candidates who did not fit the populations represented in these trials were managed with DBS of multiple distinct targets, which included ANT, CM, and less-studied nuclei-i.e., mediodorsal nucleus, pulvinar, and subthalamic nucleus. The goal of this study was to present the authors' experience with these types of cases, and to motivate future investigations that can determine the long-term efficacy of multitarget DBS. METHODS: This single-center retrospective study of adult patients with drug-resistant epilepsy who underwent multitarget DBS was performed to demonstrate the feasibility and safety of this approach, and to present seizure outcomes. Patients in this cohort had epilepsy with features that were difficult to treat with DBS of the ANT or CM nucleus alone, including multifocal/multilobar, diffuse-onset, and/or posterior-onset seizures; or both generalized and focal seizures. RESULTS: Eight patients underwent DBS of 2-3 distinct thalamic/subthalamic nuclei. DBS was performed with 2 electrodes in each hemisphere. All leads in each patient were implanted with either frontal or parietal trajectories. There were no surgical complications. Among those with > 6 months of follow-up (n = 5; range 7-21 months), all patients were responders in terms of overall seizure frequency and/or convulsive seizure frequency (i.e., ≥ 50% reduction). Two patients had adverse stimulation effects, which resolved with further programming. CONCLUSIONS: Multitarget DBS is a procedurally feasible and safe treatment strategy to maximize outcomes in patients with complex epilepsy. The authors highlight their approach to inform future studies that are sufficiently powered to assess its efficacy.

A Comprehensive Landscape of De Novo Malignancy After Double Lung Transplantation.

Although the association between post-transplant malignancy (PTM) and immunosuppressive therapy after organ transplantation has been studied, an integrated review of PTM after lung transplantation is lacking. We investigated the incidence and types of de novo PTM and its impact on survival following double lung transplantation (DLT). The incidence and type of PTM as well as the annual and cumulative risks of each malignancy after DLT were analyzed. The overall survival (OS) of recipients with or without PTM was compared by the Kaplan-Meier survival method and landmark analysis. There were 5,629 cases (23.52%) with 27 types of PTMs and incidences and OS varied according to the types of PTMs. The recipients with PTM showed a significantly longer OS than those without PTM (p < 0.001). However, while the recipients with PTM showed significantly better OS at 3, and 5 years (p < 0.001, p = 0.007), it was worse at the 10-year landmark time (p = 0.013). And the single PTM group showed a worse OS rate than the multiple PTM group (p < 0.001). This comprehensive report on PTM following DLT can help understand the risks and timing of PTM to improve the implementation of screening and treatment.

Deep brain stimulation for substance use disorder: a systematic review and meta-analysis.

Objective: Substance use disorder (SUD) is a significant public health issue with a high mortality rate. Deep brain stimulation (DBS) has shown promising results in treating SUD in certain cases. In this study, we conducted a meta-analysis to evaluate the efficacy of DBS in the treatment of SUD and reduction of relapse rates. Methods: We performed a thorough and methodical search of the existing scientific literature, adhering to the PRISMA guidelines, to identify 16 original studies that fulfilled our inclusion criteria. We used the evidence levels recommended by the Oxford Centre for Evidence-Based Medicine to assess bias. The R version 4.2.3 software was utilized to calculate the mean effect size. We estimated study heterogeneity by employing tau2 and I2 indices and conducting Cochran's Q test. Results: The results showed that DBS treatment resulted in a significant improvement in the clinical SUD scales of patients, with an average improvement of 59.6%. The observed relapse rate was 8%. The meta-analysis estimated a mean effect size of 55.9 [40.4; 71.4]. Heterogeneity analysis showed a large degree of heterogeneity among the included studies. Subgroup and meta-regression analysis based on age and SUD type suggested that DBS may be more effective for patients above 45 years of age, and for alcohol and opioid addiction compared to nicotine addiction. Conclusion: The current literature suggests that DBS has a moderate effect on SUD symptoms. However, the limited number of studies and small sample size indicate that more research is needed to better understand the factors that influence its effectiveness.

Investigation of neurophysiologic and functional connectivity changes following glioma resection using magnetoencephalography.

Background: In patients with glioma, clinical manifestations of neural network disruption include behavioral changes, cognitive decline, and seizures. However, the extent of network recovery following surgery remains unclear. The aim of this study was to characterize the neurophysiologic and functional connectivity changes following glioma surgery using magnetoencephalography (MEG). Methods: Ten patients with newly diagnosed intra-axial brain tumors undergoing surgical resection were enrolled in the study and completed at least two MEG recordings (pre-operative and immediate post-operative). An additional post-operative recording 6-8 weeks following surgery was obtained for six patients. Resting-state MEG recordings from 28 healthy controls were used for network-based comparisons. MEG data processing involved artifact suppression, high-pass filtering, and source localization. Functional connectivity between parcellated brain regions was estimated using coherence values from 116 virtual channels. Statistical analysis involved standard parametric tests. Results: Distinct alterations in spectral power following tumor resection were observed, with at least three frequency bands affected across all study subjects. Tumor location-related changes were observed in specific frequency bands unique to each patient. Recovery of regional functional connectivity occurred following glioma resection, as determined by local coherence normalization. Changes in inter-regional functional connectivity were mapped across the brain, with comparable changes in low to mid gamma-associated functional connectivity noted in four patients. Conclusion: Our findings provide a framework for future studies to examine other network changes in glioma patients. We demonstrate an intrinsic capacity for neural network regeneration in the post-operative setting. Further work should be aimed at correlating neurophysiologic changes with individual patients' clinical outcomes.

Defining the minimal clinically important difference in smartphone-based mobility after spine surgery: correlation of survey questionnaire to mobility data.

OBJECTIVE: Patient-reported outcome measures (PROMs) are the gold standard for assessing postoperative outcomes in spine surgery. However, PROMs are also limited by the inherent subjectivity of self-reported qualitative data. Recent literature has highlighted the utility of patient mobility data streamed from smartphone accelerometers as an objective measure of functional outcomes and complement to traditional PROMs. Still, for activity-based data to supplement existing PROMs, they must be validated against current metrics. In this study, the authors assessed the relationships and concordance between longitudinal smartphone-based mobility data and PROMs. METHODS: Patients receiving laminectomy (n = 21) or fusion (n = 10) between 2017 and 2022 were retrospectively included. Activity data (steps-per-day count) recorded in the Apple Health mobile application over a 2-year perioperative window were extracted and subsequently normalized to allow for intersubject comparison. PROMS, including the visual analog scale (VAS), Patient Reported Outcome Measurement Information System Pain Interference (PROMIS-PI), Oswestry Disability Index (ODI), and EQ-5D, collected at the preoperative and 6-week postoperative visits were retrospectively extracted from the electronic medical record. Correlations between PROMs and patient mobility were assessed and compared between patients who did and those who did not achieve the established minimal clinically important difference (MCID) for each measure. RESULTS: A total of 31 patients receiving laminectomy (n = 21) or fusion (n = 10) were included. Change between preoperative and 6-week postoperative VAS and PROMIS-PI scores demonstrated moderate (r = -0.46) and strong (r = -0.74) inverse correlations, respectively, with changes in normalized steps-per-day count. In cohorts of patients who achieved PROMIS-PI MCID postoperatively, indicating subjective improvement in pain, there was a 0.784 standard deviation increase in normalized steps per day, representing a 56.5% improvement (p = 0.027). Patients who did achieve the MCID of improvement in either PROMIS-PI or VAS after surgery were more likely to experience an earlier sustained improvement in physical activity commensurate to or greater than their preoperative baseline (p = 2.98 × 10-18) than non-MCID patients. CONCLUSIONS: This study demonstrates a strong correlation between changes in mobility data extracted from patient smartphones and changes in PROMs following spine surgery. Further elucidating this relationship will allow for more robust supplementation of existing spine outcome measure tools with analyzed objective activity data.

Correlation of Carpal Tunnel Syndrome 6 Score and Physical Exam Maneuvers With Electrodiagnostic Test Severity in Carpal Tunnel Syndrome: A Blinded Prospective Cohort Study.

PURPOSE: Although carpal tunnel syndrome (CTS) can be diagnosed clinically with the Carpal Tunnel Syndrome 6 (CTS-6) evaluation tool, the relationship between disease severity and CTS-6 score has not been elucidated. The purpose of our study was to determine the correlation of the CTS-6 score and other physical examination maneuvers with the carpal tunnel severity grade by electrodiagnostic testing (EDT). We hypothesized that the CTS-6 score, Durkan test, and Semmes Weinstein Monofilament Testing (SWMT) positively correlate with EDT severity. METHODS: We prospectively enrolled 105 consecutive patients who presented to the office with suspected CTS, excluding those with previous surgery, previous EDT from an outside facility, or concomitant neuropathy. Four fellowship-trained hand surgeons obtained the CTS-6 score, time to obtain a positive Durkan compression test, and SWMT of the thumb, index, and middle fingers. All patients were sent for EDT. Hand surgeons were blinded to the results of the EDT, and the electrodiagnosticians were blinded to the clinical data. We used the Bland criteria (0-6) to grade CTS severity on EDT. This grade was compared with the CTS-6 score, Durkan time, and SWMT results. RESULTS: Using Spearman correlation coefficients, we found a weakly positive correlation between a higher CTS-6 score and a higher severity grade on EDT. The mean CTS-6 score based on EDT grading were the following: (1) 14.8 (grade 0), (2) 16.0 (grade 1), (3) 14.8 (grade 2), (4) 16.7 (grade 3), (5) 18.7 (grade 4), (6) 18.3 (grade 5), and (7) 22.4 (grade 6). We also found a statistically significant association between the SWMT and a higher CTS-6 score as well as a higher severity grade on EDT. Durkan compression test did not appear to correlate with the EDT grade. CONCLUSIONS: The CTS-6 and SWMT show a positive correlation with EDT severity in CTS on the basis of the Bland criteria. The time to a positive Durkan test did not show any correlation. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Medical Cannabis in Hand Surgery: A Review of the Current Evidence.

Acute and chronic pain management remains an ongoing challenge for hand surgeons. This has been compounded by the ongoing opioid epidemic in the United States. With the increasing legalization of medical and recreational cannabis throughout the United States and other countries, previous societal stigmas about this substance keep evolving, and recognition of medical cannabis as an opioid-sparing pain management alternative is growing. A review of the current literature demonstrates a strong interest from patients regarding the use of medical cannabis for pain control. Current evidence demonstrates its efficacy and safety for chronic musculoskeletal and neuropathic pain. However, definitive conclusions regarding the efficacy of cannabis for pain control in hand and upper extremity conditions require continued investigation. The purpose of this article is to provide a general review of the mechanism of medical cannabis and a scoping review of the current evidence for its efficacy, safety, and potential applicability in hand and upper extremity conditions.

Role of postoperative radiotherapy in resected adenoid cystic carcinoma of the head and neck.

PURPOSE: Although postoperative radiotherapy (PORT) is demonstrably effective in local control of head and neck adenoid cystic carcinoma (HNACC), its application is controversial and the subset of patients who would benefit most from PORT is unknown. Herein, we analyzed the data of HNACC patients to clarify the role of PORT. METHODS: We retrospectively reviewed 187 patients with nonmetastatic HNACC who underwent surgical resection between 2005 and 2019. The study endpoints were locoregional failure-free survival (LRFFS), progression-free survival (PFS), and overall survival (OS). Subgroup analysis and recursive partitioning analysis (RPA) were performed to identify patients most likely to benefit from PORT. RESULTS: With a median follow-up of 84.7 months, the 5-year LRFFS, PFS, and OS were 70.0%, 52.6%, and 86.4%, respectively. Survival was significantly shorter in patients who experienced local failure than in those who did not (5-year OS: 88.1% vs. 80.5%, P = 0.001). The local failure rate was significantly lower in patients who underwent PORT (16.9% vs. 31.0%, P = 0.021), despite the high frequency of adverse factors. Especially, significant decreases in local failure and similar OS rates could be obtained after PORT among patients with positive margins, T2-4 stage disease, and minor salivary gland tumors. The RPA model for PFS categorized patients into four groups according to three prognostic factors (T-stage, location, and sex). The RPA model for LRFFS and OS suggested three groups based on two factors (T-stage, margin for LRFFS; T-stage, grade 3 for OS). CONCLUSION: PORT could prevent dismal survival, while significantly reducing local failures in high-risk HNACC patients.

Morphology and gene expression profiling provide complementary information for mapping cell state.

Morphological and gene expression profiling can cost-effectively capture thousands of features in thousands of samples across perturbations by disease, mutation, or drug treatments, but it is unclear to what extent the two modalities capture overlapping versus complementary information. Here, using both the L1000 and Cell Painting assays to profile gene expression and cell morphology, respectively, we perturb human A549 lung cancer cells with 1,327 small molecules from the Drug Repurposing Hub across six doses, providing a data resource including dose-response data from both assays. The two assays capture both shared and complementary information for mapping cell state. Cell Painting profiles from compound perturbations are more reproducible and show more diversity but measure fewer distinct groups of features. Applying unsupervised and supervised methods to predict compound mechanisms of action (MOAs) and gene targets, we find that the two assays not only provide a partially shared but also a complementary view of drug mechanisms. Given the numerous applications of profiling in biology, our analyses provide guidance for planning experiments that profile cells for detecting distinct cell types, disease phenotypes, and response to chemical or genetic perturbations.

Endoscopic microvascular decompression without the use of rigid head fixation.

BACKGROUND: Rigid fixation using a three-point skull clamp is a common practice during cranial surgery. Despite its frequency of use, rigid fixation is not without risk of complications including hemodynamic changes, skull fractures and venous thromboembolism. Given this, alternative head fixation should be considered when clinically appropriate. OBJECTIVE: We sought to demonstrate a safe and effective "pinless" head fixation system during endoscopic microvascular decompression (E-MVD). METHODS: Patients undergoing E-MVD were placed in the lateral position with a doughnut pillow under the head, providing support and reducing lateral neck flexion. The vertex of the cranium was angled 10 degrees downward and tape placed circumferentially in an X-shaped fashion around the head, avoiding direct pressure on the ears or eyes. The ipsilateral shoulder was pulled caudally away from the operative field and taped in place to ensure a maximal working corridor. RESULTS: Fifty-two patients underwent the E-MVD procedure with pinless head fixation without any clinical complications. Indications included trigeminal neuralgia type 1 (63.5%), trigeminal neuralgia type 2 (5.8%), hemifacial spasm (19.2%), geniculate neuralgia (7.7%) and glossopharyngeal neuralgia (3.8%). There were no intraoperative or post operative complications and operative time for patients with three-point skull clamp fixation were similar compared to pinless head fixation. CONCLUSIONS: Pinless head fixation is a suitable alternative for certain patients undergoing E-MVD and provides a way to minimize complications that can occur secondary to rigid fixation. If pinless fixation is used, diligent and continued communication with the anesthetist is necessary to ensure there is no intraoperative patient movement.

Gamma Knife radiosurgery for trigeminal neuralgia provides greater pain relief at higher dose rates.

In Gamma Knife (GK) radiosurgery, dose rate decreases during the life cycle of its radiation source, extending treatment times. Prolonged treatments influence the amount of sublethal radiation injury that is repaired during exposure, and is associated with decreased biologically-equivalent dose (BED). We assessed the impact of treatment times on clinical outcomes following GK of the trigeminal nerve - a rare clinical model to isolate the effects of treatment times. This is a retrospective analysis of 192 patients with facial pain treated across three source exchanges. All patients were treated to 80 Gy with a single isocenter. Treatment time was analyzed in terms of patient anatomy-specific dose rate, as well as BED calculated from individual patient beam-on times. An outcome tool measuring pain in three distinct domains (pain intensity, interference with general and oro-facial activities of daily living), was administered before and after intervention. Multivariate linear regression was performed with dose rate/BED, brainstem dose, sex, age, diagnosis, and prior intervention as predictors. BED was an independent predictor of the degree of improvement in all three dimensions of pain severity. A decrease in dose rate by 1.5 Gy/min corresponded to 31.8% less improvement in the overall severity of pain. Post-radiosurgery incidence of facial numbness was increased for BEDs in the highest quartile. Treatment time is an independent predictor of pain outcomes, suggesting that prescription dose should be customized to ensure iso-effective treatments, while accounting for the possible increase in adverse effects at the highest BEDs.

Objective Impact of Hematology-Oncology Hospitalist Care in an Inpatient Setting.

PURPOSE: The utilization of the hospitalist care model has increased over the past decade because of improved cost-effectiveness, quality of care, and value that it provides. Studies have shown that compared with the traditional care model, use of hospitalists provides cost-saving and improved value to hospital systems. However, the data for the use of oncology hospitalists (ONC Hosp) are sparse. In this study, we investigate the impact of inpatient ONC Hosp on 30-day readmissions, length of stay (LOS), discharge to hospice, and inpatient mortality when compared with a traditional model where outpatient oncologists manage the acute issues of hospitalized patients with cancer. METHODS: Rhode Island Hospital hired ONC Hosps to attend on the inpatient oncology service. To determine the impact of this new patient care model, we performed a retrospective review of oncology patients admitted to Rhode Island Hospital between July 1, 2012, and June 30, 2018, and compared quality outcomes of 30-day readmission, LOS, discharge to hospice, and inpatient mortality to those from the traditional care model. RESULTS: Compared with outpatient oncologists care, care by ONC Hosp was associated with a significant decrease in 30-day readmissions (23.0% v 29.6%, P = .019) and a significant increase in discharge to hospice (18.1% v 12.1%, P < .001). No significant difference was detected between LOS (P = .833) or inpatient mortality (P = .332). CONCLUSION: This study shows that compared with the traditional care model, the use of ONC Hosps has a positive impact on patient care and the potential to add value to the hospital system.

Surgical strategies in the treatment of MR-negative Cushing's Disease: a systematic review and treatment algorithm.

PURPOSE: Several surgical strategies have been proposed to treat MRI-negative Cushing's Disease. These include tumor removal, if identified, and if a tumor is not identified, resection of varying degrees of the pituitary gland, often guided by inferior petrosal sinus sampling (IPSS). The relative risks and benefits of each strategy have never been compared. METHODS: This systematic review of the literature included only studies on the results of surgery for MRI-negative patients with Cushing's Disease in which the surgical strategy was clearly described and associated remission and/or hypopituitarism rates detailed for each strategy. RESULTS: We identified 12 studies that met inclusion criteria for remission rates and 5 studies for hypopituitarism rates. We divided cases into 6 resection strategies. Remission and hypopituitarism rates for each strategy were: (1) tumor identified, resect tumor only (68%, 0%); (2) resect tumor and surrounding capsule (85%, 0%); and if the tumor was not identified (3) resect inferior 1/3 of gland (78%, no data); (4) resect 30-50% of gland based on IPSS (68%, 13%); (5) resect > 50% but < 100% of gland (65%, 9%); (6) resect entire gland (66%, 67%). Strategy 3 only contained 9 patients. CONCLUSION: Remission rates for MRI-negative Cushing's Disease support surgery as a reasonable approach. Results are best if a tumor is found. If a tumor is not identified, one can either remove one-third of the gland guided by IPSS lateralization, or remove both lateral portions along with the inferior portion leaving sufficient central gland to preserve function. Our recommendations are limited by the lack of rigorous and objective data.