Handheld Osteotome Laminectomy in Cadavers and a Case Study.

Laminectomy is a commonly performed surgery to decompress the spinal canal to relieve spinal canal stenosis secondary to a variety of etiologies such as degenerative spinal changes, fractures, tumors, vascular lesions, and infections. Advances in technologies have allowed for more precise osteotomies and offer more protection to nearby structures; however, these technologies may not always be available at some facilities. To the best of the authors' knowledge, we describe an innovative technique to perform laminectomy using a handheld osteotome, which is widely available and at low cost. Our experience with cadavers and a case study shows that the technique appears to be safe and effective and may have the potential to reduce the procedure length of a laminectomy.

An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas.

INTRODUCTION: Although chronic subdural hematoma (CSDH) is a common neurosurgical disease, there is a lack of algorithms for the treatment of asymptomatic and symptomatic CSDH. The purpose of this article is to describe an algorithm developed using our institutional experience for the treatment of symptomatic CSDH that aims to decrease symptoms and/or hematoma size or to completely resolve both. Our algorithm for treatment of symptomatic CSDH includes subdural drain (SDD) placement via twist-drill craniostomy (TDC) as the first-line treatment, followed by supplemental tissue plasminogen activator (tPA) as second-line treatment, with possible middle meningeal artery embolization (MMAE), followed by craniotomy as the last therapeutic option. This study investigated the efficacy of our institution's algorithm in treating symptomatic CSDH. METHODS: A retrospective study was conducted from 2019 to 2023 identifying patients with CSDH treated with TDC. Electronic medical records were used to gather patient demographics, clinical presentation, radiographic findings, treatment modalities, and clinical outcomes. RESULTS: There were a total of 109 patients with 128 SDD placements. All 109 patients underwent TDC; among them, 37 patients received tPA instillation with three patients requiring craniotomy. Factors including age, gender, race, mechanism of injury, blood thinner usage, Glasgow Coma Scale (GCS), neurologic exam, thickness of CSDH, and midline shift were comparable for all patients regardless of treatment received. The mean number of neomembranes was higher in patients who eventually required craniotomy (4.5) compared to those treated with TDC only (1.8) and TDC+tPA (2.1) (p=0.0035). There was a greater mean hematoma drainage in patients who received tPA instillation without craniotomy (586.7 mL) than those treated with TDC only (293.0 mL) (p<0.0001). Clinical improvement was found in 52/72 patients (72.2%) treated with TDC only, 23/34 patients (67.6%) treated with TDC+tPA only, and 0/3 patients (0.0%) treated with TDC+tPA+craniotomy. Radiographic improvement in mean thickness of CSDH and midline shift, respectively, was found in patients treated with TDC only (p<0.0001; p<0.0001) and TDC+tPA (p<0.0001; p<0.0001) but not in TDC+tPA+craniotomy (p=0.1494; p=0.0762). There were also fewer neomembranes after TDC+tPA treatment only (2.1 vs. 0.5, p<0.0001). Seven patients were readmitted that did not follow the algorithm and only patients treated following the algorithm showed clinical and radiographic improvement. CONCLUSIONS: Using our institutional algorithm, our study demonstrates successful clinical outcomes in treating symptomatic CSDH and recurrent CSDH with minimally invasive therapeutic interventions including SDD via TDC and tPA, thereby minimizing the utilization of more invasive interventions including craniotomy.

Prevalence of Central Line-Associated Bloodstream Infections (CLABSI) in Intensive Care and Medical-Surgical Units.

BACKGROUND:  Central line-associated bloodstream infections (CLABSIs) remain an important preventable healthcare-associated infection with a 2020 rate of 0.87 (per 1,000 central line days) in the United States intensive care units (ICU). METHODS:  This was a retrospective cohort study of all adult patients in our institution. The total number of central venous catheter (CVC) insertions and line days were determined using daily unit logs maintained by unit managers. Central line insertion practice (CLIP) compliance was calculated as the total number of CLIP forms submitted divided by the total number of newly-inserted CVCs with and without associated CLIP forms as determined by unit logs. RESULTS: A total of 1,125 CVCs were reviewed (448 - ICU and 677 - medical-surgical units). Of the 13 CLABSI, one patient had internal jugular (IJ), one patient had subclavian (SC), four patients had femoral, three patients had peripherally inserted central catheter (PICC) and four patients had hemodialysis catheters. Patients with CLABSI had CVC inserted for a range of five to 92 days with the average number of line days being 29 days. CONCLUSION:  Based on the analysis of our CLABSI patient population, we recommend our institution implement the following criteria to decrease the prevalence of CLABSI: All patients receiving a CVC must adhere to CLIP documentation in all units, any femoral or HD CVC placed without a CLIP form should have the line changed within 48 hours, those patients with a femoral CVC or hemodialysis catheter in place for four days or greater with an abnormal WBC (<4.0 or >11 mg/dL) or abnormal temperature (<97.0F or >100.4F) should be considered for catheter exchange, and those patients with an IJ, SC, or PICC CVC in place for seven days or greater with an abnormal WBC or abnormal temperature should have the catheter changed.

Thoracic Pedicle Screw Placement Utilizing Hands-On Training Session on Three-Dimensional Models.

The utilization of three-dimensional (3D) models has been an important element of medical education. We demonstrate a three-dimensionally-printed (3DP) thoracic spine model for use in the teaching of freehand pedicle screw placement. Neurosurgical residents with varying years of experience practiced screw placement on these models. Residents were timed, and models were evaluated for medial and lateral breaches. Overall, this technical report describes the utility of 3D spine models in the training of thoracic pedicle screw placement. The tactile feedback from the 3D models was designed to represent both cortical and cancellous bones.

External Ventricular Drain (EVD) Placement Using a Hands-On Training Session on a Simple Three-Dimensional (3D) Model.

Neurosurgery is a demanding field with small margins of error within the operative field. Small errors can yield devastating consequences. Simulation has been proposed as a methodology for improving surgical skills within the neurosurgical realm. This study was conducted to investigate a novel realistic design for a clinical simulation based, low-cost alternative of external ventricular drain (EVD) placement, an essential basic neurosurgical procedure that is necessary for clinicians to master. A low-cost three-dimensional (3D) printed head using thermoplastic polylactic acid was designed with the tactile feedback of outer table, cancellous bone, and inner tables for drilling with replaceable frontal bones pieces for multi-use purposes. An agar gel filled with water was designed to simulate tactile passage through the cortex and into the ventricles. Neurosurgical and emergency resident physicians participated in a didactic session and then attempted placement of an EVD using the model to gauge the simulated model for accuracy and realism. Positioning, procedural time, and realism was evaluated. Improvements in procedural time and positioning were identified for both neurosurgical and emergency medicine (EM) residents. Catheter placement was within ideal position for all participants by the third attempt. All residents stated they felt more comfortable with placement with subsequent attempts. Neurosurgical residents subjectively noted similarities in tactile feedback during drilling compared to in-vivo. A low-cost realistic 3D printed model simulating basic neurosurgical procedures demonstrated improved procedural times and precision with neurosurgical and EM residents. Further, similarities between in-vivo tactile feedback and the low-cost simulation technology was noted. This low cost-model may be used as an adjunct for teaching to promote early procedural competency in neurosurgical techniques to promote learning without predisposition to patient morbidity.

Magnesium Levels and Diastolic Blood Pressure (DBP) as a Vasospasm Prediction Metric in Patients With Aneurysmal Subarachnoid Hemorrhage (SAH).

Introduction Vasospasm is a significant cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study is to evaluate a possible link between vasospasm in patients with aneurysmal SAH and magnesium and blood pressure levels. Methods Subjects were selected based on chart review of patients presenting to a comprehensive stroke center in Southern California with aneurysmal SAH. 27 were included based on the following criteria: patients greater than 18 years of age, aneurysmal SAH, clinically symptomatic vasospasms and at least one diagnostic confirmation - either from a transcranial doppler (TCD) or digital subtraction angiogram (DSA). The following exclusion criteria also applied: 1) incomplete documentation in the medical record; 2) patients <18 years of age; and 3) patients without TCD measurements. Results In an overall analysis of all patients with or without vasospasm, it was found that the presence of vasospasm was significantly correlated with diastolic blood pressures (DBPs) on day of vasospasm with an r value of 0.418 and p<0.001. Average daily DBPs throughout hospital stay were also correlated with vasospasm with an r-value of 0.455 and p<0.001. Changes in magnesium overall were also significantly related to left Lindegaard ratios with an r value of -0.201 and p value of 0.032. Lindegaard ratios were significantly correlated with age with r values of 0.510, p<0.001, and r=-0.482, p<0.001 for left and right, respectively. A change in magnesium was inversely correlated to the left Lindegaard ratio with an n of 31 and p value of 0.014 (r= -0.439) in patients with vasospasm. We also found a lower incidence of vasospasm in patients older than 65. Conclusion Monitoring magnesium and increases in DBP might be effective as a prophylactic adjunct method in patients with SAH in an effort to predict clinical vasospasm.

Efficacy of Incentive Spirometer in Increasing Maximum Inspiratory Volume in an Out-Patient Setting.

Background Incentive spirometry (IS) is the mainstay of care in postoperative patients that has been heavily studied in the inpatient setting. Studies have shown that the utilization of IS improves lung volumes and reduces the rate of pneumonia in post-surgical patients. However, the literature is ambiguous on its benefit as many studies also demonstrate no significant benefit, especially in comparison to early ambulation. Our study sought to determine whether a consistent IS regimen can improve lung function in an outpatient setting. Methods This prospective cohort study included patients in a physical medicine and rehabilitation clinic setting during the COVID pandemic. Patients with severe respiratory disease, baseline cough, those unable to perform deep breathing, fever greater than 100.4 F due to non-pulmonary on initial evaluation, or inability to fill out the forms and complete the study were excluded. Each participant was given the IS along with hands-on instruction on how to use the device and accurately record measurements. Patients were asked to lie down and inhale and exhale through the tube ten times. They were asked to mark the highest volume during their 10 breaths. Patients were instructed to complete this exercise three times a day for 30 days. Patients were also asked to perform light exercises or walking for 20 minutes per day three times a week and postural drainage. Patients were instructed to call their primary care physician if a 20% or more decrease from their baseline was noted or if they experienced any new coughs, fever, or shortness of breath during the 30 days of exercise. Results A total of 48 patients enrolled in the study with a (median) age of 58.0 years (SD 10.2 years), 21 females and 27 males. Baseline maximal inspiration for study participants was 1885.4 mL prior to exercise, with a subsequent increase in lung capacity observed for all participants enrolled in the study. At the end of the study period, week four, the average maximal inspiratory volume was 2235.4 mL. Paired t-test showed a significant difference between baseline (1885.4) and maximum (2235.4) volumes (t=-4.59, p<0.0001). Analysis of variance (ANOVA) showed no significant difference among Week 1-4 averages (F=1.08, p=0.36). None of the participants reported any symptoms (fever, coughing, shortness of breath) or COVID-19 infection during the 30-days period. None of the participants reported contacting primary care physicians.  Conclusion When prescribed daily breathing exercises with an incentive spirometer, study participants experienced a 16% increase in maximal inspiratory volume over a span of 30 days and did not need to contact their primary care physician during the study period.

Osteopathic Manipulative Treatment to Optimize the Glymphatic Environment in Severe Traumatic Brain Injury Measured With Optic Nerve Sheath Diameter, Intracranial Pressure Monitoring, and Neurological Pupil Index.

Background Traumatic brain injury (TBI) has a complex pathophysiology that has historically been poorly understood. New evidence on the pathophysiology, molecular biology, and diagnostic studies involved in TBI have shed new light on optimizing rehabilitation and recovery. The goal of this study was to assess the effect of osteopathic manipulative treatment (OMT) on peripheral and central glial lymphatics in patients with severe TBI, brain edema, and elevated intracranial pressure (ICP) by measuring changes in several parameters regularly used in management. Methodology This was a retrospective study at a level II trauma center that occurred in 2018. The study enrolled patients with TBI, increased ICP, or brain edema who had an external ventricular drain placed. Patients previously underwent a 51-minute treatment with OMT with an established protocol. Patients received 51 minutes of OMT to the head, neck, and peripheral lymphatics. The ICP, cerebrospinal fluid (CSF) drainage, optic nerve sheath diameter (ONSD) measured by ultrasonography, and Neurological Pupil Index (NPi) measured by pupillometer were recorded before, during, and after receiving OMT. Results A total of 11 patients were included in the study, and 21 points of data were collected from the patients meeting inclusion criteria who received OMT. There was a mean decrease in the ONSD of 0.62 mm from 6.24 mm to 5.62 mm (P = 0.0001). The mean increase in NPi was 0.18 (P = 0.01). The mean decrease in ICP was 3.33 mmHg (P= 0.0001). There was a significant decrease in CSF output after treatment (P = 0.0001). Each measurement of ICP, ONSD, and NPi demonstrated a decrease in overall CSF volume and pressure after OMT compared to CSF output and ICP prior to OMT. Conclusions This study demonstrates that OMT may help optimize glial lymphatic clearance of CSF and improve brain edema, interstitial waste product removal, NPi, ICP, CSF volume, and ONSD. A holistic approach including OMT may be considered to enhance management in TBI patients. As TBI is a spectrum of disease, utilizing similar techniques may be considered for all forms of TBI including concussions and other diseases with brain edema. The results of this study can better inform future trials to specifically study the effectiveness of OMT in post-concussive treatment and in those with mild-to-moderate TBI.

Correction: Predictive Value of Credit Score on Surgery Resident and Fellow Academic and Professional Performance.

[This corrects the article DOI: 10.7759/cureus.15946.].

Predictive Value of Credit Score on Surgery Resident and Fellow Academic and Professional Performance.

Introduction Surgical specialties consistently remain among the most competitive residency and fellowship programs with some of the highest rates of unmatched applicants. Attrition in surgical specialties is as high as 30% and particularly problematic given the extended duration of training and limited number of positions. Applicants are traditionally evaluated using a streamlined set of objective metrics, such as board scores, class rank, leadership, letters of recommendation, research productivity, and volunteerism. Consumer credit scores have been shown to be predictors of personality and work performance, however, the literature has yet to explore consumer credit histories in the context of surgical resident and fellow performance. This study aims to determine whether consumer credit scores of surgery residents and fellows are predictive of academic and professional performance. Methods This is a multi-institutional observational survey study across all American Council of Graduate Medical Education and Royal College of Physicians and Surgeons accredited surgical residency and fellowship programs in the United States and Canada. Ninety-nine surgical residents and fellows with educational status of post-graduate year two or higher participated in this study. Dichotomous (yes or no) survey items were formulated to assess performance indicators in the domains of notable achievements and awards, research output, written examination performance, professionalism, and surgical/technical skills. Three-digit Fair Isaac Corporation (FICO) credit scores, a widely accepted consumer reporting score, were collected to avoid calculation variability between algorithms.  Results Surgical residents and fellows reported credit scores between 611( fair) and 853 (exceptional) with a median (interquartile range) of 774 (715-833). The majority of participants 51.5%(51) reported very good credit scores. Those with higher credit scores (very good/exceptional) were 377% more likely to have one or more positive performance indicators OR (95% CI) = 3.77 (1.43-9.97). Similarly, residents with lower credit scores (fair/good) were only 40% more likely to have one or more negative performance indicators. The credit score has a moderate ability to distinguish between the presence and absence of positive performance indicators (area under the curve {AUC} = 0.70, p = 0.001). The use of 753 as a credit score cutoff is 78.9% sensitive and 52.4% specific for discerning surgery residents and fellows with one or more positive performance indicators. The credit score did not significantly discern those with negative performance indicators. Conclusions While credit score was significantly functional in discerning those with and without positive performance indicators, sensitivity and specificity rates leave much to be desired. This study suggests credit score may have a utility as a companion to traditional metrics used in identifying candidates for surgery residencies and fellowships who will have positive performance in the domains of research productivity, written examination performance, and professional awards and recognition. Additional studies are needed to assess this utility on a larger scale.

Using the Decrease in Trauma Admissions During the COVID-19 Pandemic to Evaluate Compliance With Stay-at-Home and Social Distancing Guidelines.

Introduction The coronavirus disease 2019 (COVID-19) virus was declared a pandemic on March 10, 2020 by the World Health Organization (WHO) and has massively burdened healthcare systems with cases exponentially rising throughout the United States and the rest of the world. Since implementing precautions to reduce the spread of this disease, emergency departments have seen a decrease in the number of traumas. By evaluating the differences in the number of trauma admissions in different subgroups of patients, we can assess where to target messaging to increase compliance with these precautions. In this study, we aim to analyze the effect of the COVID-19 pandemic on trauma admissions. Methodology This was a retrospective review of the trauma database at our institution, a level 2 trauma center in Southern California, to assess the impact of COVID-19 on the number of traumas. The inclusion criteria were patients activated as traumas, regardless of age. Patients were excluded from the study if they did not have complete information in the trauma database. Data were stratified by date into two groups: (a) COVID period (January to April 2020) and (b) pre-COVID period (January to April 2019). The primary endpoint of this study was to determine whether there was a significant change in the number of patients presenting as trauma during the COVID-19 pandemic. This difference was analyzed and divided into subgroups based on age and trauma type. Results In our review, an average of 279 patients per month presented as trauma from January to April in 2019, and an average of 222 patients per month presented as trauma from January to April 2020 (p = 0.049). We found a significant decrease in the number of patients presenting with the chief complaint of fall and vehicular accident, but a nonsignificant difference in patients presenting as assaults or pedestrian accidents. There was also a significant decrease in the number of traumas in the 18-39 and 65+ age groups and a nonsignificant decrease in the 40-64 age group. It was also noted that the number of trauma admissions in May 2020 increased to 253 compared to 269 in 2019. This increase was most notable in the 18-39 and 40-64 age groups. Discussion As seen in the data, the most notable year-over-year difference was seen in March and April. In California specifically, a stay-at-home order was set in place in March, which was in conjunction with the WHO's declaration of a pandemic. An interesting finding was the significant decrease in patients with traumas in the age groups of 18-39 and 65+ from 2019 to 2020. There was a smaller, nonsignificant decrease in patients aged 40-64. This would be a good group to target with future messaging to increase compliance with health advisories. There was also a notable increase in the number of traumas in May 2020, signaling an end to the cooperation of the majority of people, also indicating that further measures needed to be enacted in all groups. Conclusions COVID-19 has disrupted social structures worldwide. As the pandemic continued, even the observers of stay-at-home and social distancing measures, the 18-39 age group, became fatigued with the guidelines and ventured out into the warming weather and summer activities. This difference in trauma admission due to COVID-19 between subsequent years can highlight the behavioral changes in our patient population and can be further extrapolated to target additional messaging to help reduce the spread of COVID-19.

The Impact of the COVID-19 Pandemic on Resident Physicians Well-Being in the Surgical and Primary Care Specialties in the United States and Canada.

PURPOSE:  The COVID-19 pandemic disrupted the professional, social, and spiritual activities of resident physicians around the world, impacting wellness and personal relationships. Moreover, social distancing caused significant limitations or shutdown of places of worship, including churches, synagogues, mosques, etc. Our goal was to survey resident physicians in primary care and surgical subspecialties in the United States (U.S.) and Canada and to examine the effect of the COVID-19 pandemic on their well-being. METHODS:  An international cross-sectional study was performed in November 2020, using an anonymous survey of programs in the U.S. and Canada, containing 20 questions to assess the impact of the pandemic on resident participation in social and spiritual activities and the effects on their wellness, and personal relationships. The emails with survey links attached were sent to individual program coordinators from accredited residency training programs in the United States and Canada. This consisted of programs accredited by the American Osteopathic Association (AOA), The Royal College of Physicians and Surgeons of Canada (RCPSC), and the Accreditation Council of Graduate Medical Education (ACGME). The survey was evenly divided among surgical programs (General Surgery, Neurological Surgery, Orthopedic Surgery, Urological Surgery, and Integrated Surgical Residency Programs such as Plastic Surgery, Cardiothoracic Surgery, Pediatric Surgery, and Vascular Surgery) as well as primary care programs (Internal Medicine and Family Medicine). RESULTS:  A total of 196 residents, 60 primary care residents, and 136 surgery residents participated in the study. Ninety-six participants (49%) were female, and 98 of the participants (50%) were male, with the remainder two residents identifying as "Other." Of the primary care residents, the majority (39, 65%) were female. Conversely, the majority (77, 57%) of surgery residents were male. CONCLUSION:  The COVID-19 pandemic has affected the social lives, relationships, and spiritual well-being of both surgical and primary care resident physicians. However, primary care residents reported significantly greater engagement in personal relationships and were more likely to express feelings of mental and physical exhaustion, prohibiting social attendance.

Risks, Benefits, and the Optimal Time to Resume Deep Vein Thrombosis Prophylaxis in Patients with Intracranial Hemorrhage.

Introduction It is common to start all patients on chemical prophylaxis for deep vein thrombosis (DVT) in order to decrease the risk of venous thromboembolism (VTE) and the associated adverse effects, including the potential for fatal pulmonary embolism (PE). There is no consensus in the literature on the optimal time to resume chemical DVT prophylaxis in patients who present with intracranial hemorrhage requiring neurosurgical intervention. The practice is variable and practitioner dependent. There can be difficulty in balancing the increased risk of further intracranial hemorrhage versus the benefit of starting DVT prophylaxis to prevent VTE. Method A retrospective review of patients that had diagnosis of intracranial hemorrhage (ICH) defined as epidural hematoma (EDH), subdural hematoma (SDH), or intra-parenchymal hematoma (IPH), was performed using the neurosurgical census at our institution. The review consisted of adult patients greater than 18 years old with a diagnosis of intracranial hemorrhage. Type of intracranial hemorrhage, method of neurosurgical intervention (whether surgical, bedside procedure, or both), day post-procedure prophylaxis was resumed, and the type of chemical prophylaxis used (subcutaneous heparin (SQH) versus enoxaparin) were recorded. The patient's sex, Glasgow Coma Scale on presentation and discharge, length of hospital stay, and length of intensive care unit (ICU) stay were also recorded. Patients with previously diagnosed bleeding dyscrasia, previously diagnosed DVT or PE, patients without post-procedure cranial imaging (CT or MRI), and patients without post-procedure duplex ultrasound for DVT screening were excluded. Patients were monitored with head CT for possible expansion of ICH after resumption of therapy. Furthermore, we investigated whether the patient developed an adverse effect such as venous thromboembolism including deep vein thrombosis and/or pulmonary embolism during the post-procedure period when they were not on chemical prophylaxis. Results A total of 94 patients were analyzed in our study. Nine (9.6%) had an EDH, seventeen (18.1%) had an IPH, and sixty-eight (72.3%) had a SDH. The three most common procedures were craniectomy (28.7%), craniotomy (34%), and subdural drain placement (28.7%). The most common agent for chemical DVT prophylaxis was SQH in 78% of patients. There was no statistically significant association between type of chemical DVT prophylaxis used with respect to either ICU length of stay or hospital length of stay. Change in GCS (the difference of GCS on presentation versus on discharge) was found to have statistically significant relationship with the use of chemical DVT prophylaxis. Furthermore, patients were found to have no statistically significant association with re-bleed or new hemorrhage upon starting chemical DVT prophylaxis, regardless of the type of ICH. Conclusion The rates of DVT diagnosis did not seem to be significantly affected by the specific type of chemical prophylaxis that was used. ICU and hospital length of stay were not adversely affected by starting prophylaxis for VTE in patients with ICH. On the contrary, an improvement in GCS (on presentation versus discharge) was associated with starting chemical DVT prophylaxis in ICH patients within 24 hours post-procedure.

Comparison of Lumbar Fusion for Back Pain and Opioid Use at County and Managed Care Hospitals.

CONTEXT: Opioids may be prescribed for the short-term management of acute-onset back pain in the setting of trauma or for long-term management of chronic back pain. More than 50% of regular opioid users report taking them for back pain. OBJECTIVE: To investigate whether surgical intervention reduces opioid requirements by patients taking opioids for back pain and whether there is a difference between county and managed care hospitals in this postoperative reduction of opioid requirement. METHODS: A retrospective medical record review of 118 patients who underwent elective lumbar fusion at 4 hospitals (2 county hospitals and 2 managed care hospitals) was conducted. Opioid requirements before and after surgical intervention and at the 30-day outpatient follow-up were evaluated. RESULTS: Forty medical records were included in the study. An overall decrease in opioid use was found in the postoperative follow-up phase after lumbar fusion in both the county and managed care hospitals. This reduction was statistically significant at 3 of 4 hospitals (P<0.01). When the data were pooled by facility type, the significance remained for county facilities (P<.01) but not managed care facilities (P=.18). Moreover, there was a significant decrease in opioid use during the postoperative inpatient phase for county compared with managed care facilities (P=.0427). The pain rating reported by patients during the hospital stay was significantly higher at county compared with managed care hospitals (P=.0088); however, the difference at discharge was not significant (P=.14). CONCLUSION: Our study indicates that lumbar fusion is associated with a significant decrease in opioid use (P<.05) compared with nonsurgical management. Overall, the difference in decreased opioid use between county and managed care hospitals after lumbar fusion was not significant.

Polymer-driven crystallization.

Obtaining well-diffracting crystals of macromolecules remains a significant barrier to structure determination. Here we propose and test a new approach to crystallization, in which the crystallization target is fused to a polymerizing protein module, so that polymer formation drives crystallization of the target. We test the approach using a polymerization module called 2TEL, which consists of two tandem sterile alpha motif (SAM) domains from the protein translocation Ets leukemia (TEL). The 2TEL module is engineered to polymerize as the pH is lowered, which allows the subtle modulation of polymerization needed for crystal formation. We show that the 2TEL module can drive the crystallization of 11 soluble proteins, including three that resisted prior crystallization attempts. In addition, the 2TEL module crystallizes in the presence of various detergents, suggesting that it might facilitate membrane protein crystallization. The crystal structures of two fusion proteins show that the TELSAM polymer is responsible for the majority of contacts in the crystal lattice. The results suggest that biological polymers could be designed as crystallization modules.

Will clinical parameters reliably predict external ventricular drain-associated ventriculitis: Is frequent routine cerebrospinal fluid surveillance necessary?

BACKGROUND: The placement of an external ventricular drain (EVD) for monitoring and treatment of increased intracranial pressure is not without risk, particularly for the development of associated ventriculitis. The goal of this study was to investigate whether changes in cerebrospinal fluid (CSF), serum, or clinical parameters are correlated with the development of ventriculitis before it occurs, allowing for the determination of optimal timing of CSF collection. METHODS: An observational retrospective study was conducted between January 2006 and May 2012. A total of 466 patients were identified as having an in-situ EVD placed. Inclusion criteria were age >18 years, glasgow coma scale (GCS) 4-15, and placement of EVD for any indication. Exclusion criteria included recent history of meningitis, cerebral abscess, cranial surgery or open skull fracture within the previous 30 days. A broad definition of ventriculitis was used to separate patients into three initial categories, two of which had sufficient patients to proceed with analysis: suspected ventriculitis and confirmed ventriculitis. CSF sampling was conducted on alternating weekdays. RESULTS: A total of 466 patients were identified as having an EVD and 123 patients were included in the final analysis. The incidence of ventriculitis was 8.8%. Only the ratio of glucose CSF: serum <0.5 was found to be of statistical significance, though not correlated to developing a ventriculitis. CONCLUSIONS: This study demonstrates no reliable tested CSF, serum, or clinical parameters that are effectively correlated with the development of ventriculitis in an EVD patient. Thus, we recommend and will continue to draw CSF samples from patients with in-situ EVDs on our current schedule for as long as the EVD remains in place.

Anti-epileptic prophylaxis in traumatic brain injury: A retrospective analysis of patients undergoing craniotomy versus decompressive craniectomy.

BACKGROUND: Seizures account for significant morbidity and mortality early in the course of traumatic brain injury (TBI). Although there is sufficient literature suggesting short-term benefits of antiepileptic drugs (AEDs) in post-TBI patients, there has been no study to suggest a time frame for continuing AEDs in patients who have undergone a decompressive craniectomy for more severe TBI. We examined trends in a level-II trauma center in southern California that may provide guidelines for AED treatment in craniectomy patients. METHODS: A retrospective analysis was performed evaluating patients who underwent decompressive craniectomy and those who underwent a standard craniotomy from 2008 to 2012. RESULTS: Out of the 153 patients reviewed, 85 were included in the study with 52 (61%) craniotomy and 33 (39%) craniectomy patients. A total of 78.8% of the craniotomy group used phenytoin (Dilantin), 9.6% used levetiracetam (Keppra), 5.8% used a combination of both, and 3.8% used topiramate (Topamax). The craniectomy group used phenytoin 84.8% and levetiracetam 15.2% of the time without any significant difference between the procedural groups. Craniotomy patients had a 30-day seizure rate of 13.5% compared with 21.2% in craniectomy patients (P = 0.35). Seizure onset averaged on postoperative day 5.86 for the craniotomy group and 8.14 for the craniectomy group. There was no significant difference in the average day of seizure onset between the groups P = 0.642. CONCLUSION: Our study shows a trend toward increased seizure incidence in craniectomy group, which does not reach significance, but suggests they are at higher risk. Whether this higher risk translates into a benefit on being on AEDs for a longer duration than the current standard of 7 days cannot be concluded as there is no significant difference or trend on the onset date for seizures in either group. Moreover, a prospective study will be necessary to more profoundly evaluate the duration of AED prophylaxis for each one of the stated groups.

Third Ventricular Glioblastoma Multiforme: Case Report and Literature Review.

Background Glioblastoma multiforme (GBM) typically presents in the supratentorial white matter, commonly within the centrum semiovale as a ring-enhancing lesion with areas of necrosis. An atypical presentation of this lesion, both anatomically as well as radiographically, is significant and must be part of the differential for a neoplasm in this anatomical location. Case Description We present a case of a 62-year-old woman with headaches, increasing somnolence, and cognitive decline for several weeks. Magnetic resonance imaging demonstrated mild left ventricular dilatation with a well-marginated, homogeneous, and nonhemorrhagic lesion located at the ceiling of the third ventricle within the junction of the septum pellucidum and fornix, without exhibiting the typical radiographic features of hemorrhage or necrosis. Final pathology reports confirmed the diagnosis of GBM. Conclusion This case report describes an unusual location for the most common primary brain neoplasm. Moreover, this case identifies the origin of a GBM related to the paracentral ventricular structures infiltrating the body of the fornix and leaves of the septum pellucidum. To our knowledge this report is the first reported case of a GBM found in this anatomical location with an entirely atypical radiographic presentation.

Histoplasmosis with Deep CNS Involvement: Case Presentation with Discussion and Literature Review.

Central nervous system (CNS) histoplasmosis is rare and difficult to diagnose because it is often overlooked or mistaken for other pathologies due to its nonspecific symptoms. A 32-year-old Hispanic man with advanced acquired immunodeficiency virus presented with altered mental status and reported confusion for the past 3 months. He had a Glasgow Coma Scale of 12, repetitive nonfluent speech, and a disconjugate gaze with a right gaze preference. Lung computed tomography (CT) findings indicated a pulmonary histoplasmosis infection. Magnetic resonance imaging of the brain revealed a ring-enhancing lesion in the left caudate nucleus. A CT-guided left retroperitoneal node biopsy was performed and indicated a benign inflammatory process with organisms compatible with fungal yeast. Treatment with amphotericin B followed by itraconazole was initiated in spite of negative cerebrospinal fluid (CSF) cultures and proved effective in mitigating associated CNS lesions and resolving neurologic deficits. The patient was discharged 3 weeks later in stable condition. Six weeks later, his left basal ganglia mass decreased. Early recognition of symptoms and proper steps is key in improving outcomes of CNS histoplasmosis. Aggressive medical management is possible in the treatment of intracranial deep mass lesions, and disseminated histoplasmosis with CNS involvement can be appropriately diagnosed and treated, despite negative CSF and serology studies.