Use of spinal cord stimulation in treatment of intractable headache diseases.

Headache diseases remain one of the leading causes of disability in the world. With the development of neuromodulation strategies, high cervical spinal cord stimulation (hcSCS) targeting the trigeminocervical complex has been deployed to treat refractory headache diseases. In this article, we review the proposed mechanism behind hcSCS stimulation, and the various studies that have been described for the successful use of this treatment strategy in patients with chronic migraine, cluster headache, and other trigeminal autonomic cephalalgias.

Health-related quality of life disparities among Hispanic/Latinx patients with nephrolithiasis.

It is documented that Hispanic/Latinx kidney stone formers have inferior health-related quality of life (HRQoL) compared to the general population. We hypothesized that socioeconomic factors drive HRQoL disparities. Specifically, we sought to determine if medical insurance type is associated with HRQoL disparities among Hispanic/Latinx stone formers. This was a prospective cohort observational study of patients with kidney stones across the University of San Diego Health Care System. Patients enrolled from June 2018 to August 2020 completed a validated Wisconsin Stone Quality of Life questionnaire (WISQoL). Patient characteristics and self-reported HRQoL were compared between Hispanic/Latinx and non-Hispanic/Latinx stone formers using MANCOVA and ordinal logistic regression. Matched group comparisons were performed based on age, gender, body mass index, stone symptoms, and insurance type using MACOVA. A total of 270 patients were enrolled (Hispanic/Latinx n = 88; non-Hispanic/Latinx n = 182). Hispanic/Latinx stone formers had higher rates of public insurance at baseline (p < 0.001) with significantly lower HRQoL [social impact (p = 0.007)]. However, a matched cohort comparison demonstrated no differences. On multivariate analysis, private insurance increased the likelihood of having higher HRQoL (OR 2.21, p = 0.021), while stone symptoms (OR = 0.06, p < 0.001) and emergency department visits (OR = 0.04, p = 0.008) decreased chances of higher HRQoL. Ethnicity was not a significant factor in HRQoL scores on multivariate analysis. Our analysis suggests that differences in HRQoL among Hispanic/Latinx stone formers may be primarily driven by socioeconomic factors as opposed to clinical or racial differences. Specifically, source of insurance appears to have significant effect on HRQoL in this ethnic group.

MicroRNA-218 instructs proper assembly of hippocampal networks.

The assembly of the mammalian brain is orchestrated by temporally coordinated waves of gene expression. Post-transcriptional regulation by microRNAs (miRNAs) is a key aspect of this program. Indeed, deletion of neuron-enriched miRNAs induces strong developmental phenotypes, and miRNA levels are altered in patients with neurodevelopmental disorders. However, the mechanisms used by miRNAs to instruct brain development remain largely unexplored. Here, we identified miR-218 as a critical regulator of hippocampal assembly. MiR-218 is highly expressed in the hippocampus and enriched in both excitatory principal neurons (PNs) and GABAergic inhibitory interneurons (INs). Early life inhibition of miR-218 results in an adult brain with a predisposition to seizures. Changes in gene expression in the absence of miR-218 suggest that network assembly is impaired. Indeed, we find that miR-218 inhibition results in the disruption of early depolarizing GABAergic signaling, structural defects in dendritic spines, and altered intrinsic membrane excitability. Conditional knockout of Mir218-2 in INs, but not PNs, is sufficient to recapitulate long-term instability. Finally, de-repressing Kif21b and Syt13, two miR-218 targets, phenocopies the effects on early synchronous network activity induced by miR-218 inhibition. Taken together, the data suggest that miR-218 orchestrates formative events in PNs and INs to produce stable networks.

Standardizing Perioperative Medications to Be Used in an Enhanced Recovery After Surgery Program Is Feasible in Percutaneous Nephrolithotomy Patients.

Introduction: The objective of this process improvement project was to determine the effect of enhanced recovery after surgery (ERAS) protocol for percutaneous nephrolithotomy (PCNL) patients with respect to quality of life (QOL) and pain management in the postoperative recovery period. Methods: An electronic-based medical record ERAS orders protocol for PCNL was instituted at an academic medical center in July 2020. The protocol utilized a pain control regimen designed to minimize opioid medication use postoperatively. We prospectively evaluated PCNL patients' QOL through the Wisconsin Stone Quality of Life (WISQOL) survey and Patient-Reported Outcomes Measurement System (PROMIS) at routine perioperative visits. To assess any opioid reduction benefit of the ERAS protocol, we reviewed an age-matched historical cohort n = 66 (before ERAS implementation) to serve as a comparison cohort with respect to opioid usage. Results: After an inception cohort of 95 patients, 55 ERAS patients remained available for assessment with the WISQOL and PROMIS surveys. In comparison with the non-ERAS cohort, the ERAS cohort represented larger stones, more supine positioning, higher blood loss, shorter hospital stay, and more use of access sheath. ERAS patients received a significantly lower amount of opioids compared with non-ERAS patients upon discharge narcotic usage (116.13 morphine milliequivalent [MME] vs 39.57 MME, p = 0.0001). Compared with their preoperative evaluation, the ERAS cohort had significantly improved QOL scores at 1 week, which sustained through 8 weeks postoperatively. Moreover, pain intensity and pain interference scores were improved at 8 weeks postoperatively for ERAS patients compared with their preoperative time point. Conclusions: We demonstrate that standardizing medications in early efforts toward a PCNL ERAS protocol is feasible and allows for reduced opioid use by patients while achieving early and sustained postprocedure QOL.

Understanding Causes for Admission in Planned Ambulatory Percutaneous Nephrolithotomy.

Introduction: For treatment of nephrolithiasis, ambulatory percutaneous nephrolithotomy (aPCNL) is growing in popularity for select patients. The aim of this study was to investigate the safety and efficacy of a set of aPCNL selection criteria as well as search for predictors of failed aPCNL resulting in inpatient admission. Materials and Methods: We reviewed all percutaneous nephrolithotomy (PCNL) patients from 2016 to 2020. A total of 175 met selection criteria for aPCNL and were included. Primary outcome was safety and efficacy, and secondary outcome was to identify predictors of inpatient stay. Demographic and perioperative data were analyzed with both descriptive and inferential statistics. Results: In total, between 2016 and 2020, 552 patients underwent PCNL, with 175 of them meeting criteria for aPCNL. One hundred thirty-four of the 175 (76.6%) of these patients were discharged the same day as the surgery and 41 patients were admitted. On univariate analysis, patients who required upper pole access or multiple accesses (p = 0.038) American Society of Anesthesiologists >2 (p = 0.005), or postoperative nephrostomy (PCN) tube (p < 0.001) were more likely to be admitted after surgery. On multivariate analysis, only postoperative PCN was significantly associated with admission (p = 0.015). Regarding reasons for unsuccessful aPCNL, 19.5% of admissions were attributed to intraoperative complications, 7% to social causes, 12.2% to postoperative complications, 14.6% to uncontrolled pain, and 34.1% to unexpected intraoperative procedures. Conclusions: aPCNL using selection criteria is safe and effective, with postoperative PCN predicting the possible necessity for conversion to inpatient admission. Furthermore, our study provides a practical algorithm for those opting to provide aPCNL to patients.

Minimally Invasive Percutaneous Nephrolithotomy: Initial North American Experience.

Introduction and Objectives: The goal of this study is to evaluate the outcomes in a cohort of patients who underwent minimally invasive percutaneous nephrolithotomy (MIP) at a single institution from 2017 to 2019. Methods: Sixty patients at a single institution with two different surgeons underwent MIP from 2017 to 2019. The MIP technique uses a proprietary nephroscope with a "vacuum" technique for stone evacuation. Patients were identified who had postoperative CT scan imaging available for direct review. A prospectively maintained database was queried along with retrospective chart review to evaluate the stone-free rate defined as no stones on CT imaging. Preoperative, intraoperative, and postoperative variables were analyzed including initial stone size, access type (fluoroscopic vs ultrasonic), access location, operative positioning (supine vs prone), operative time, and 60-day complications. Results: Forty-six of 60 patients had CT imaging postoperatively that were reviewable. Of these, 43% (n = 20) were stone free as defined by no identifiable fragments seen, 11% (n = 5) had residual fragments 0 to 2 mm, 7% (n = 3) had residual fragments 2 to 4 mm, and 39% (n = 18) had residual fragments >4 mm. Mean initial stone size was 21 mm (1.9-84 mm). Sixty percent (n = 28) of the patients were discharged the same day as surgery. Fifty-one percent (n = 24) of access was achieved through ultrasound alone. Seventeen percent of patients (n = 8) had a complication within 30 days of surgery. All complications were Clavien III or lower with unplanned return to operating room rate of 2% (n = 1). Conclusions: We present North America's first single institution analysis of MIP cases with acceptable outcomes comparable with both retrograde intrarenal surgery and standard percutaneous nephrolithotomy. The exact role of MIP in renal stone disease needs to be determined by future studies that critically assess their outcomes.