Temporal dynamics of peripheral neutrophil and lymphocytes following acute ischemic stroke.

BACKGROUND: The immune response to acute ischemic stroke (AIS) is implicated in diagnosis, prognosis, and intervention; however, the temporal dynamics of leukocytes following AIS are poorly understood. The purpose of this study was to characterize peripheral leukocyte dynamics following AIS among individuals with poor and favorable outcomes. METHODS: A retrospective chart review was conducted among patients with a diagnosis of AIS who were treated at a comprehensive stroke center across a 3-year timeframe. Groups were defined according to stroke outcomes. Patients with poor outcomes were distinguished from those with favorable outcomes by discharge National Institute of Health Stroke Score, infarct size, and Modified Rankin Scale. Leukocyte counts were compared among controls and AIS outcome groups. RESULTS: The neutrophil-lymphocyte ratio (NLR) calculated at 48-72 h post-AIS was identified as the strongest predictor of outcome. NLR was significantly higher in the poor outcome group (8.68 ± 0.93) compared with both the favorable outcome (4.5 ± 0.51, p = 0.009) and control group (4.33 ± 0.66, p < 0.001). Patients with a 48-72 h NLR ≥ 4.58 were 5.58 times more likely to have a poor outcome than AIS patients with an NLR < 4.58. CONCLUSIONS: The results of this study improve the understanding of the immune response in AIS. Low neutrophil count relative to high lymphocyte count at 48-72 h post-AIS should be considered a predictor of a favorable stroke outcome. Conversely, high neutrophil count relative to low lymphocyte count at 48-72 h post-AIS should be considered a predictor of a poor stroke outcome.

Surgical Management of Brain Tumors with Focused Ultrasound.

Focused ultrasound is a novel technique for the treatment of aggressive brain tumors that uses both mechanical and thermal mechanisms. This non-invasive technique can allow for both the thermal ablation of inoperable tumors and the delivery of chemotherapy and immunotherapy while minimizing the risk of infection and shortening the time to recovery. With recent advances, focused ultrasound has been increasingly effective for larger tumors without the need for a craniotomy and can be used with minimal surrounding soft tissue damage. Treatment efficacy is dependent on multiple variables, including blood-brain barrier permeability, patient anatomical features, and tumor-specific features. Currently, many clinical trials are currently underway for the treatment of non-neoplastic cranial pathologies and other non-cranial malignancies. In this article, we review the current state of surgical management of brain tumors using focused ultrasound.

Acute Respiratory Distress Syndrome in Patients with Subarachnoid Hemorrhage: Incidence, Predictive Factors, and Impact on Mortality.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) is a known predictor of poor outcomes in critically ill patients. We sought to examine the role ARDS plays in outcomes in subarachnoid hemorrhage (SAH) patients. Prior studies investigating the incidence of ARDS in SAH patients did not control for SAH severity. Hence, we sought to determine the incidence ARDS in patients diagnosed with aneurysmal SAH and investigate the predisposing risk factors and impact upon outcomes. METHODS: A retrospective cohort study was conducted using the National Inpatient Sample (NIS) database for the years 2008 to 2014. Multivariate stepwise regression analysis was performed to identify the risk factors and outcome associated with developing ARDS in the setting of SAH. RESULTS: We identified 170,869 patients with non-traumatic subarachnoid hemorrhage, of whom 6962 were diagnosed with ARDS and of those 4829 required mechanical ventilation. ARDS more frequently developed in high grade SAH patients (1.97 ± 0.05 vs. 1.15 ± 0.01; p < 0.0001). Neurologic predictors of ARDS included cerebral edema (OR 1.892, CI 1.180-3.034, p = 0.0035) and medical predictors included cardiac arrest (OR 4.642, CI 2.273-9.482, p < 0.0001) and cardiogenic shock (OR 2.984, CI 1.157-7.696, p = 0.0239). ARDS was associated with significantly worse outcomes (15.5% vs. 52.9% discharged home, 63.0% vs. 40.8% discharged to rehabilitation facility and 21.5% vs. 6.3% in-hospital mortality). CONCLUSION: Patients with SAH who developed ARDS were less likely to be discharged home, more likely to need rehabilitation and had a significantly higher risk of mortality. The identification of risk factors contributing to ARDS is helpful for improving outcomes and resource utilization.

Fornicotomy for the Treatment of Epilepsy: An Examination of Historical Literature in the Setting of Modern Operative Techniques.

Fornicotomy has been used to treat intractable temporal lobe epilepsy with mixed success historically; however, modern advances in stereotactic, neurosurgical, and imaging techniques offer new opportunities to target the fornix with greater precision and safety. In this review, we discuss the historical uses and quantify the outcomes of fornicotomy for the treatment of temporal lobe epilepsy, highlight the potential mechanisms of benefit, and address what is known about the side effects of the procedure. We find that fornicotomy, with or without anterior commissurotomy, resulted in 61% (83/136) of patients having some seizure control benefit. We discuss the potential operative approaches for targeting the fornix, including laser ablation and the use of focused ultrasound ablation. More work is needed to address the true efficacy of fornicotomy in the modern surgical setting. This review is intended to serve as a framework for developing this approach.

West Virginia's Sugary Drink Tax Examining Print Media Frames in Local News Sources.

Introduction: Framing is an important aspect of the policy process that helps the public and decision makers sort through and resolve highly charged claims about an issue. Through slight changes in the presentation of issues, a framing effect may alter public support. The way a proposed sugary drink tax is discussed in public discourse and by the media significantly influences policy acceptance. Given the public health significance of obesity and diabetes in West Virginia (WV) the study of media frames employed to represent a sugary drink tax policy is useful. Methods: Using quantitative content analysis, this study assessed news articles-published over 7 years by news outlets in WV-to determine the frames that were employed. Results: Pro-tax arguments appeared more often in these articles. In both pro- and anti-tax arguments, a personal behavior or economic frame appeared more frequently. The more common anti-tax arguments focused on the tax being regressive and not changing personal behavior. The pro-tax arguments focused more often on increases in state revenues and people selecting healthier beverages. Implications: Given the significance of obesity and diabetes in WV, the study of media frames that represent the sugary drink tax should provide valuable guidance to inform strategies that utilize public discourse and media coverage to influence policy acceptance. However, since WV has not been able to get approval for its sugary drink tax, it may be beneficial to examine other elements of agenda setting including issue generation tactics, mobilizing structures, and political opportunities.

Utility of sodium fluorescein for achieving resection targets in glioblastoma: increased gross- or near-total resections and prolonged survival.

OBJECTIVE: It is commonly reported that achieving gross-total resection of contrast-enhancing areas in patients with glioblastoma (GBM) improves overall survival. Efforts to achieve an improved resection have included the use of both imaging and pharmacological adjuvants. The authors sought to investigate the role of sodium fluorescein in improving the rates of gross-total resection of GBM and to assess whether patients undergoing resection with fluorescein have improved survival compared to patients undergoing resection without fluorescein. METHODS: A retrospective chart review was performed on 57 consecutive patients undergoing 64 surgeries with sodium fluorescein to treat newly diagnosed or recurrent GBMs from May 2014 to June 2017 at a teaching institution. Outcomes were compared to those in patients with GBMs who underwent resection without fluorescein. RESULTS: Complete or near-total (≥ 98%) resection was achieved in 73% (47/64) of fluorescein cases. Of 42 cases thought not to be amenable to complete resection, 10 procedures (24%) resulted in gross-total resection and 15 (36%) resulted in near-total resection following the use of sodium fluorescein. No patients developed any local or systemic side effects after fluorescein injection. Patients undergoing resection with sodium fluorescein, compared to the non-fluorescein-treated group, had increased rates of gross- or near-total resection (73% vs 53%, respectively; p < 0.05) as well as improved median survival (78 weeks vs 60 weeks, respectively; p < 0.360). CONCLUSIONS: This study is the largest case series to date demonstrating the beneficial effect of utilizing sodium fluorescein as an adjunct in GBM resection. Sodium fluorescein facilitated resection in cases in which it was employed, including dominant-side resections particularly near speech and motor regions. The cohort of patients in which sodium fluorescein was utilized had statistically significantly increased rates of gross- or near-total resection. Additionally, the fluorescein group demonstrated prolonged median survival, although this was not statistically significant. This work demonstrates the promise of an affordable and easy-to-implement strategy for improving rates of total resection of contrast-enhancing areas in patients with GBM.

A Novel Method for Training Mice in Visuo-Tactile 3-D Object Discrimination and Recognition.

Perceiving, recognizing and remembering 3-dimensional (3-D) objects encountered in the environment has a very high survival value; unsurprisingly, this ability is shared among many animal species, including humans. The psychological, psychophysical and neural basis for object perception, discrimination, recognition and memory has been extensively studied in humans, monkeys, pigeons and rodents, but is still far from understood. Nearly all 3-D object recognition studies in the rodent used the "novel object recognition" paradigm, which relies on innate rather than learned behavior; however, this procedure has several important limitations. Recently, investigators have begun to recognize the power of behavioral tasks learned through reinforcement training (operant conditioning) to reveal the sensorimotor and cognitive abilities of mice and to elucidate their underlying neural mechanisms. Here, we describe a novel method for training and testing mice in visual and tactile object discrimination, recognition and memory, and use it to begin to examine the underlying sensory basis for these cognitive capacities. A custom-designed Y maze was used to train mice to associate one of two 3-D objects with a food reward. Out of nine mice trained in two cohorts, seven reached performance criterion in about 20-35 daily sessions of 20 trials each. The learned association was retained, or rapidly re-acquired, after a 6 weeks hiatus in training. When tested under low light conditions, individual animals differed in the degree to which they used tactile or visual cues to identify the objects. Switching to total darkness resulted only in a transient dip in performance, as did subsequent trimming of all large whiskers (macrovibrissae). Additional removal of the small whiskers (microvibrissae) did not degrade performance, but transiently increased the time spent inspecting the object. This novel method can be combined in future studies with the large arsenal of genetic tools available in the mouse, to elucidate the neural basis of object perception, recognition and memory.

PEEK Implant: A Case Report Illustrating the Benefits for Correcting Craniosynostosis Asymmetry.

BACKGROUND: Unilateral coronal synostosis can cause aesthetically unappealing plagiocephaly, which often requires surgical correction. The techniques utilized for this operation have continued to evolve. Unfortunately, some patients who have fronto-orbital advancement will have residual asymmetry. CASE: We present a case of a 21 year-old female with residual asymmetry who was suffering from facial swelling and refractory trigeminal neuralgia. It was decided to perform an additional surgery with polytheretheketone (PEEK) implant to restore normal symmetry and provide symptomatic relief. CONCLUSION: The ideal fit PEEK implant provided excellent cosmetic results and the operation relieved her symptoms. We provide a detailed discussion on why PEEK implants are great options for these types of cases due to advanced pre-surgical planning technology, ease of placement, and durability over time.

Magnetic Resonance Imaging Parameters and Their Impact on Survival of Patients with Glioblastoma: Tumor Perfusion Predicts Survival.

BACKGROUND: Many prognostic factors influence overall survival (OS) of patients with glioblastoma. Despite gross total resection and Stupp protocol adherence, many patients have poor survival. Perfusion magnetic resonance imaging may assist in diagnosis, treatment monitoring, and prognostication. METHODS: This retrospective study of 36 patients with glioblastoma assessed influence of preoperative magnetic resonance imaging parameters reflecting tumor cell density and vascularity and patient age on OS. RESULTS: The area under curve based on optimal receiver operating characteristic curves for the perfusion parameters normalized relative tumor blood volume (n_rTBV) and normalized relative tumor blood flow (n_rTBF) were 0.92 and 0.89, respectively, and the highest among all imaging parameters and age. OS showed strongly negative correlations with corrected n_rTBV (R = -0.70; P < 0.001) and n_rTBF (R = -0.67; P < 0.001). The Cox model, which included age and imaging parameters, demonstrated that n_rTBV and n_rTBF were most predictive of OS, with hazard ratios of 5.97 (P = 0.0001) and 8.76 (P = 0.0001), respectively, compared with 1.63 (P = 0.19) for age. Eighteen patients with corrected n_rTBV ≤2.5 (best cutoff value) had a median OS of 15.1 months (95% confidence interval (CI), 11.34-21.25) compared with 2.8 months (95% CI, 1.48-4.03; P < 0.001) for 18 patients with corrected n_rTBV >2.5. Twenty-four patients with n_rTBF ≤2.79 had a median OS of 12 months (95% CI, 10.46-17.9) compared with 2.8 months for 12 patients with n_rTBF >2.79 (95% CI, 1.31-4.2; P < 0.001). CONCLUSIONS: The dominant predictors of OS are normalized perfusion parameters n_rTBV and n_rTBF. Preoperative perfusion imaging may be used as a surrogate to predict glioblastoma aggressiveness and survival independent of treatment.

Glioblastoma Survival Outcomes at a Tertiary Hospital in Appalachia: Factors Impacting the Survival of Patients Following Implementation of the Stupp Protocol.

BACKGROUND: Glioblastoma is a fatal brain cancer with low median and yearly survival rates. Standard of care for treating glioblastoma is gross total resection (GTR) coupled with the Stupp protocol, but various factors influence the interventions undertaken and survival achieved. As health disparities exist in rural areas, survival in these areas needs to be assessed to understand which factors detract from the successes of these standard medical interventions. METHODS: We retrospectively determined impact of age at diagnosis, number of lesions, the molecular marker O6-methylguanine methyltransferase (MGMT), extent of surgery, and completion of the Stupp protocol on survival in patients treated at West Virginia University Hospitals. We also compared our findings with a pre-Stupp protocol study done in West Virginia in 1996. RESULTS: Age <60 years at diagnosis, having the MGMT gene methylated, having a unifocal tumor, receiving GTR, adhering to the Stupp protocol, and undergoing a treatment course of GTR followed by the Stupp protocol significantly increased survival. Comparison with the 1996 study showed that although overall median survival has not increased, all interventions involving GTR have resulted in a significantly higher survival. CONCLUSIONS: We can serve our patient population by offering GTR to all adult patients with glioblastoma when no contraindications exist and ensuring that patients follow the Stupp protocol. After discharge, the Stupp protocol may not be followed or completed for a variety of reasons. In the future, we aim to assess these reasons and analyze other significant interventional and socioeconomic factors that influence survival.