Improving heart rate monitoring in the obese with time-of-flight photoplethysmography (TOF-PPG): a quantitative analysis of source-detector-distance effect.

Commercial photoplethysmography (PPG) sensors rely on the measurement of continuous-wave diffuse reflection signals (CW-DRS) to monitor heart rate. Using Monte Carlo modeling of light propagation in skin, we quantitatively evaluate the dependence of continuous-wave photoplethysmography (CW-PPG) in commercial wearables on source-detector distance (SDD). Specifically, when SDD increases from 0.5 mm to 3.3 mm, CW-PPG signal increases by roughly 846% for non-obese (NOB) skin and roughly 683% for morbidly obese (MOB) skin. Ultimately, we introduce the concept of time-of-flight PPG (TOF-PPG) which can significantly improve heart rate signals. Our model shows that the optimized TOF-PPG improves heart rate monitoring experiences by roughly 47.9% in NOB and 93.2% in MOB when SDD = 3.3 mm is at green light. Moving forward, these results will provide a valuable source for hypothesis generation in the scientific community to improve heart rate monitoring.

Characteristics of Emergency Medicine Residency Programs With Unfilled Positions in the 2023 Match.

STUDY OBJECTIVE: The unprecedented number of unfilled emergency medicine post-graduate year 1 (PGY-1) residency positions in the 2023 National Resident Matching Program shocked the emergency medicine community. This study investigates the association between emergency medicine program characteristics and the likelihood of unfilled positions in the 2023 Match. METHODS: This cross-sectional, observational study examined 2023 National Resident Matching Program data, focusing on program type, length, location, size, proximity to other programs, previous American Osteopathic Association (AOA) accreditation, first accreditation year, and emergency department ownership structure. We constructed a generalized linear mixed model with a logistic linking function to determine predictors of unfilled positions. RESULTS: A total of 554 of 3,010 (18.4%) PGY-1 positions at 131 of 276 (47%) emergency medicine programs went unfilled in the 2023 Match. In our model, predictors included having unfilled positions in the 2022 Match (odds ratio [OR] 48.14, 95% confidence interval [CI] 21.04 to 110.15), smaller program size (less than 8 residents, OR 18.39, 95% CI 3.90 to 86.66; 8 to 10 residents, OR 6.29, 95% CI 1.50 to 26.28; 11 to 13 residents, OR 5.88, 95% CI 1.55 to 22.32), located in the Mid Atlantic (OR 14.03, 95% CI 2.56 to 77.04) area, prior AOA accreditation (OR 10.13, 95% CI 2.82 to 36.36), located in the East North Central (OR 6.94, 95% CI 1.25 to 38.47) area, and corporate ownership structure (OR 3.21, 95% CI 1.06 to 9.72). CONCLUSION: Our study identified 6 characteristics associated with unfilled emergency medicine residency positions in the 2023 Match. These findings may be used to guide student advising and inform decisions by residency programs, hospitals, and national organizations to address the complexities of residency recruitment and implications for the emergency medicine workforce.

Real-time intraoperative surgical telepathology using confocal laser endomicroscopy.

OBJECTIVE: Communication between neurosurgeons and pathologists is mandatory for intraoperative decision-making and optimization of resection, especially for invasive masses. Handheld confocal laser endomicroscopy (CLE) technology provides in vivo intraoperative visualization of tissue histoarchitecture at cellular resolution. The authors evaluated the feasibility of using an innovative surgical telepathology software platform (TSP) to establish real-time, on-the-fly remote communication between the neurosurgeon using CLE and the pathologist. METHODS: CLE and a TSP were integrated into the surgical workflow for 11 patients with brain masses (6 patients with gliomas, 3 with other primary tumors, 1 with metastasis, and 1 with reactive brain tissue). Neurosurgeons used CLE to generate video-flow images of the operative field that were displayed on monitors in the operating room. The pathologist simultaneously viewed video-flow CLE imaging using a digital tablet and communicated with the surgeon while physically located outside the operating room (1 pathologist was in another state, 4 were at home, and 6 were elsewhere in the hospital). Interpretations of the still CLE images and video-flow CLE imaging were compared with the findings on the corresponding frozen and permanent H&E histology sections. RESULTS: Overall, 24 optical biopsies were acquired with mean ± SD 2 ± 1 optical biopsies per case. The mean duration of CLE system use was 1 ± 0.3 minutes/case and 0.25 ± 0.23 seconds/optical biopsy. The first image with identifiable histopathological features was acquired within 6 ± 0.1 seconds. Frozen sections were processed within 23 ± 2.8 minutes, which was significantly longer than CLE usage (p < 0.001). Video-flow CLE was used to correctly interpret tissue histoarchitecture in 96% of optical biopsies, which was substantially higher than the accuracy of using still CLE images (63%) (p = 0.005). CONCLUSIONS: When CLE is employed in tandem with a TSP, neurosurgeons and pathologists can view and interpret CLE images remotely and in real time without the need to biopsy tissue. A TSP allowed neurosurgeons to receive real-time feedback on the optically interrogated tissue microstructure, thereby improving cross-functional communication and intraoperative decision-making and resulting in significant workflow advantages over the use of frozen section analysis.

Nationwide Trends in Carotid Endarterectomy and Carotid Artery Stenting in the Post-CREST Era.

Background and Purpose- The CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) demonstrated equivalent composite outcomes between carotid endarterectomy (CEA) and carotid artery stenting (CAS) for treating carotid stenosis. We investigated nationwide trends in these procedures and associated periprocedural stroke, myocardial infarction, death, cost, and readmission rates since CREST outcomes were published. Methods- We queried the Nationwide Readmissions Database to identify patients undergoing CEA and CAS for asymptomatic and symptomatic carotid stenosis from 2010 to 2015. Patients were matched based on demographics, comorbidities, and severity of illness. Results- In total, 378 354 CEA and 57 273 CAS patients were treated during this 6-year period. CEA volume decreased by an average of 2669 procedures annually (P=0.001) with stable CAS volume (P=0.225). After matching, CEA patients had a higher rate of periprocedural stroke than CAS patients, driven by increased stroke risk in symptomatic CEA patients (8.1% versus 5.6%; odds ratio, 1.47 [CI, 1.29-1.68]; P<0.001) but a lower rate of overall inpatient mortality (0.8% versus 1.4%; odds ratio, 0.57 [CI, 0.48-0.68]; P<0.001). CEA patients were less likely to be readmitted within 30 days (7.2% versus 8.0%; odds ratio, 0.90 [CI, 0.84-0.96]; P=0.018) and 90 days (12.3% versus 14.1%; odds ratio, 0.86 [CI, 0.81-0.90]; P<0.001), and mean hospital costs were lower for CEA compared with CAS ($14 433 versus $19 172; P<0.001). Conclusions- The procedural treatment of carotid stenosis has changed dramatically in the post-CREST era. When matched for characteristics and illness severity, patients undergoing CEA had a higher rate of perioperative stroke than patients undergoing CAS, primarily among symptomatic patients. These findings are in contrast to the findings of CREST, which showed nearly twice the risk of stroke in CAS patients compared with CEA patients. CEA was associated with lower procedure cost and readmission rate.

DNA-Compatible Copper-Catalyzed Oxidative Amidation of Aldehydes with Non-Nucleophilic Arylamines.

We report a DNA-compatible protocol for synthesizing amides from DNA-bound aldehydes and non-nucleophilic arylamines including aza-substituted anilines, 2-aminobenzimidazoles, and 3-aminopyrazoles. The reactions were carried out at room temperature and provided reasonable conversions and wide functional group compatibility. The reactions were also successful when employing aryl and aliphatic aldehydes. In addition, qPCR and NGS data suggested no negative impact on DNA integrity after the copper-mediated oxidative amidation reaction.

National trends in hospital readmission following transsphenoidal surgery for pituitary lesions.

PURPOSE: Several institutions recently published their experiences with unplanned readmissions rates after transsphenoidal surgery for pituitary lesions. Readmission rates on a national level, however, have not been explored in depth. We investigated nationwide trends in this procedure and associated independent predictors, costs, and causes of 30-day readmission. METHODS: The Nationwide Readmissions Database was queried to identify patients 18 and older who underwent transsphenoidal surgery for pituitary lesion resection (2010-2015). National trends and statistical variances were calculated based on weighted, clustered, and stratified sample means. RESULTS: Of the weighted total of 44,759 patients treated over the 6-year period, 4658 (10.4%) were readmitted within 30 days. Readmission rates did not change across the survey period (P = 0.71). Patients readmitted had a higher prevalence of comorbidities than those not readmitted (82.5% vs. 78.4%, respectively, P < 0.001), experienced more postoperative complications (47.2% vs. 31.8%, P < 0.001), and had a longer length of stay (6.59 vs. 4.23 days, P < 0.001) during index admission. The most common causes for readmission were SIADH (17.5%) and other hyponatremia (16.4%). Average total readmission cost was $12,080 with no significant trend across the study period (P = 0.25). Predictors for readmission identified included diabetes mellitus, psychological disorders, renal failure, and experiencing diabetes insipidus during the index admission. CONCLUSION: Unplanned readmission is an important quality metric. While transsphenoidal pituitary surgery is a relatively safe procedure, 30-day readmission rates and costs have not declined. Future studies on institutional protocols targeting these identified predictors to prevent readmission are necessary to decrease readmission rates on a national scale.

Use of a wrist-mounted device for continuous outpatient physiologic monitoring after transsphenoidal surgery: a pilot study.

PURPOSE: Patients who undergo transsphenoidal surgery can experience hormonal, electrolyte, and fluid disturbances in the postoperative period leading to outpatient readmissions for medical management. Our goal was to determine whether use of a wrist-mounted physiologic tracking device is feasible in this setting and whether changes or trends in these parameters after discharge can help predict aberrant physiology in these patients. METHODS: Wrist-mounted physiologic tracking devices that transmit data via Bluetooth to a mobile device were used to monitor patients. Preoperative baseline data and postoperative data were aggregated daily to compare within-patient and between-patient trends. RESULTS: Of 11 patients enrolled in the study, 1 was readmitted for symptomatic hyponatremia. Device data completeness ranged from 78 to 93% with the exception of oxygen saturation (25% completeness). The patient with hyponatremia had a significantly lower baseline level of activity compared with other patients. Nonreadmitted patient activity variables (steps, calories, and distance) decreased by 48-52% after the operation (P < 0.001). The activity variables for the patient with hyponatremia were statistically unchanged after the operation; however, the patient did experience a significant decrease in heart rate compared with baseline. CONCLUSION: Deployment of a wrist-based physiologic tracking device is feasible for surgical patients in elective clinical practice. Overall, the device was associated with good patient adherence and high patient satisfaction. Patient activity significantly decreased after surgery. A significant decrease in heart rate was detected in a patient with hyponatremia who required readmission, which reflects the known intravascular volume expansion in this state.

Clinical, pathologic, and imaging characteristics of pituitary null cell adenomas as defined according to the 2017 World Health Organization criteria: a case series from two pituitary centers.

PURPOSE: The 2017 World Health Organization classification of pituitary tumors redefined pituitary null cell adenomas (NCAs) by restricting this diagnostic category to pituitary tumors that are negative for pituitary transcription factors and adenohypophyseal hormones. The clinical behavior of this redefined entity has not been widely studied, and this is a major shortcoming of the classification. This study evaluated the imaging and clinical features of NCAs from two pituitary centers and compared them with those of gonadotroph adenomas (GAs). METHODS: Imaging, pathologic, and clinical characteristics of NCAs and GAs were retrospectively reviewed. Tumor immunohistochemistry was performed to confirm absence of adenohypophyseal hormones and pituitary transcription factor expression. RESULTS: Thirty-one NCAs were compared with 38 GAs. NCAs were more likely to invade the cavernous sinus (15/31 [48%] vs. 5/38 [13%], P = .003) and had a higher proliferative index (i.e., MIB-1 > 3%, 11/31 [35%] vs. 5/38 [13%], P = .04). Gross total resection was less likely in the NCA group (19/31 [61%] vs. 33/38 [87], P = .02). Progression-free survival was worse in the NCA cohort (5-year progression-free survival, 0.70 vs. 1.00; P = .011, by log-rank test). CONCLUSIONS: Compared with GAs, NCAs are more invasive at the time of presentation and have a more aggressive clinical course. This study provides evidence that NCAs represent a distinct clinicopathologic entity with behavior that differs adversely from that of GAs. This may inform clinical decision-making, including frequency of postoperative tumor surveillance and timing of adjunctive treatments.

High-throughput screening identifies small molecules that bind to the RAS:SOS:RAS complex and perturb RAS signaling.

K-RAS is mutated in approximately 30% of human cancers, resulting in increased RAS signaling and tumor growth. Thus, RAS is a highly validated therapeutic target, especially in tumors of the pancreas, lung and colon. Although directly targeting RAS has proven to be challenging, it may be possible to target other proteins involved in RAS signaling, such as the guanine nucleotide exchange factor Son of Sevenless (SOS). We have previously reported on the discovery of small molecules that bind to SOS1, activate SOS-mediated nucleotide exchange on RAS, and paradoxically inhibit ERK phosphorylation (Burns et al., PNAS, 2014). Here, we describe the discovery of additional, structurally diverse small molecules that also bind to SOS1 in the same pocket and elicit similar biological effects. We tested >160,000 compounds in a fluorescence-based assay to assess their effects on SOS-mediated nucleotide exchange. X-Ray structures revealed that these small molecules bind to the CDC25 domain of SOS1. Compounds that elicited high levels of nucleotide exchange activity in vitro increased RAS-GTP levels in cells, and inhibited phospho ERK levels at higher treatment concentrations. The identification of structurally diverse SOS1 binding ligands may assist in the discovery of new molecules designed to target RAS-driven tumors.

Patient out-of-pocket spending in cranial neurosurgery: single-institution analysis of 6569 consecutive cases and literature review.

OBJECTIVE With drastic changes to the health insurance market, patient cost sharing has significantly increased in recent years. However, the patient financial burden, or out-of-pocket (OOP) costs, for surgical procedures is poorly understood. The goal of this study was to analyze patient OOP spending in cranial neurosurgery and identify drivers of OOP spending growth. METHODS For 6569 consecutive patients who underwent cranial neurosurgery from 2013 to 2016 at the authors' institution, the authors created univariate and multivariate mixed-effects models to investigate the effect of patient demographic and clinical factors on patient OOP spending. The authors examined OOP payments stratified into 10 subsets of case categories and created a generalized linear model to study the growth of OOP spending over time. RESULTS In the multivariate model, case categories (craniotomy for pain, tumor, and vascular lesions), commercial insurance, and out-of-network plans were significant predictors of higher OOP payments for patients (all p < 0.05). Patient spending varied substantially across procedure types, with patients undergoing craniotomy for pain ($1151 ± $209) having the highest mean OOP payments. On average, commercially insured patients spent nearly twice as much in OOP payments as the overall population. From 2013 to 2016, the mean patient OOP spending increased 17%, from $598 to $698 per patient encounter. Commercially insured patients experienced more significant growth in OOP spending, with a cumulative rate of growth of 42% ($991 in 2013 to $1403 in 2016). CONCLUSIONS Even after controlling for inflation, case-mix differences, and partial fiscal periods, OOP spending for cranial neurosurgery patients significantly increased from 2013 to 2016. The mean OOP spending for commercially insured neurosurgical patients exceeded $1400 in 2016, with an average annual growth rate of 13%. As patient cost sharing in health insurance plans becomes more prevalent, patients and providers must consider the potential financial burden for patients receiving specialized neurosurgical care.

Acrolein and thiol-reactive electrophiles suppress allergen-induced innate airway epithelial responses by inhibition of DUOX1 and EGFR.

Acrolein is a major thiol-reactive component of cigarette smoke (CS) that is thought to contribute to increased asthma incidence associated with smoking. Here, we explored the effects of acute acrolein exposure on innate airway responses to two common airborne allergens, house dust mite and Alternaria alternata, and observed that acrolein exposure of C57BL/6 mice (5 ppm, 4 h) dramatically inhibited innate airway responses to subsequent allergen challenge, demonstrated by attenuated release of the epithelial-derived cytokines IL-33, IL-25, and IL-1α. Acrolein and other anti-inflammatory thiol-reactive electrophiles, cinnamaldehyde, curcumin, and sulforaphane, similarly inhibited allergen-induced production of these cytokines from human or murine airway epithelial cells in vitro. Based on our previous observations indicating the importance of Ca2+-dependent signaling, activation of the NADPH oxidase DUOX1, and Src/EGFR-dependent signaling in allergen-induced epithelial secretion of these cytokines, we explored the impact of acrolein on these pathways. Acrolein and other thiol-reactive electrophiles were found to dramatically prevent allergen-induced activation of DUOX1 as well as EGFR, and acrolein was capable of inhibiting EGFR tyrosine kinase activity via modification of C797. Biotin-labeling strategies indicated increased cysteine modification and carbonylation of Src, EGFR, as well as DUOX1, in response to acrolein exposure in vitro and in vivo, suggesting that direct alkylation of these proteins on accessible cysteine residues may be responsible for their inhibition. Collectively, our findings indicate a novel anti-inflammatory mechanism of CS-derived acrolein and other thiol-reactive electrophiles, by directly inhibiting DUOX1- and EGFR-mediated airway epithelial responses to airborne allergens.

The Midline Catheter: A Clinical Review.

BACKGROUND: Venous access in the emergency department (ED) is an often under-appreciated procedural skill given the frequency of its use. The patient's clinical status, ongoing need for laboratory investigation, and intravenous therapeutics guide the size, type, and placement of the catheter. The availability of trained personnel and dedicated teams using ultrasound-guided insertion techniques in technically difficult situations may also impact the selection. Appropriate device selection is warranted on initial patient contact to minimize risk and cost. OBJECTIVE: To compare venous access device indications and complications, highlighting the use of midline catheters as a potentially cost-effective and safe approach for venous access in the ED. DISCUSSION: Midline catheters (MC) offer a comparable rate of device-related bloodstream infection to standard peripheral intravenous catheters (PIV), but with a significantly lower rate than peripherally inserted central catheters (PICC) and central venous catheters (CVC) (PIV 0.2/1000, MC 0.5/1000, PICC 2.1-2.3/1000, CVC 2.4-2.7/1000 catheter days). The average dwell time of a MC is reported as 7.69-16.4 days, which far exceeds PIVs (2.9-4.1 days) and is comparable to PICCs (7.3-16.6 days). Cost of insertion of a MC has been cited as comparable to three PIVs, and their use has been associated with significant cost savings when placed to avoid prolonged central venous access with CVCs or in patients with difficult-to-access peripheral veins. Placement of a MC includes modified Seldinger and accelerated, or all-in-one, Seldinger techniques with or without ultrasound guidance, with a high rate of first-attempt success. CONCLUSION: The MC is a versatile venous access device with a low complication rate, long dwell time, and high rate of first-attempt placement. Its utilization in the ED in patients deemed to require prolonged hospitalization or to have difficult-to-access peripheral vasculature could reduce cost and risk to patients.

Percutaneous Placement of Permanent Metallic Stents in the Cystic Duct to Treat Obstructive Cholecystitis.

This report presents a series of five patients unsuitable for surgery who had nonretrievable self-expanding metallic stents deployed along the cystic duct as treatment for benign and malignant causes of gallbladder obstruction. Techniques are described for draining cholecystitis, removing gallstones, bypassing gallbladder obstructions, and inserting metallic stents across the cystic duct to restore permanent antegrade gallbladder drainage in acute and chronic cholecystitis. Symptoms resolved in all cases, and stents remained patent for as long as 22 months. This procedure may be an effective alternative to cholecystectomy or long-term gallbladder drainage for patients in inoperable condition.

National treatment trends, complications, and predictors of in-hospital charges for the surgical management of craniopharyngiomas in adults from 2007 to 2011.

OBJECT: Treatment of craniopharyngiomas is one of the most demanding and controversial neurosurgical procedures performed. The authors sought to determine the factors associated with hospital charges and fees for craniopharyngioma treatment to identify possible opportunities for improving the health care economics of inpatient care. METHODS: The authors analyzed the hospital discharge database of the Nationwide Inpatient Sample (NIS) covering the period from 2007 through 2011 to examine national treatment trends for adults (that is, those older than 18 years) who had undergone surgery for craniopharyngioma. To predict the drivers of in-hospital charges, a multistep regression model was developed that accounted for patient demographics, acuity measures, comorbidities, hospital characteristics, and complications. RESULTS: The analysis included 606 patients who underwent resection of craniopharyngioma; 353 resections involved a transsphenoidal approach (58%) and 253 a transfrontal approach (42%). The mean age (± SD) of patients was 47.7 ± 16.3 years. The average hospital length of stay (LOS) was 7.6 ± 9 days. The mean hospital charge (± SD) was $92,300 ± $83,356. In total, 48% of the patients experienced postoperative diabetes insipidus or an electrolyte abnormality. A multivariate regression model demonstrated that LOS, hospital volume for the selected procedure, the surgical approach, postoperative complications, comorbidities, and year of surgery were all significant predictors of in-hospital charges. The statistical model accounted for 54% of the variance in in-hospital charge. CONCLUSIONS: This analysis of inpatient hospital charges in patients undergoing craniopharyngioma surgery identified key drivers of charges in the perioperative period. Prospective studies designed to evaluate the long-term resource utilization in this complex patient population would be a useful future direction.

Ultrasound investigation of leg position to enhance femoral vein exposure for cannulation.

BACKGROUND: Femoral venous access is an essential part of patient care in the emergency department (ED). However, current medical literature and texts have not dealt with it much using actual patient anatomy. OBJECTIVES: This study aimed to show that manipulation of the lower extremities may alter the anatomy to a more favorable position for cannulation. METHODS: Ultrasound examination was conducted on a prospective sample of ED patients to evaluate anatomical variance of the femoral artery and vein overlap as well as the change in femoral vein diameter with leg position. Bilateral measurements of the diameter of the vein were taken at three different leg positions (straight, abduction, and abduction with external rotation). RESULTS: This study enrolled a total of 132 ED patients. Of these, 122 (92%) patients showed some degree of overlap on the right and 126 (95%) patients showed some degree of overlap on the left. There was a statistically significant decrease in the percentage of overlap when moving the leg from a straightened position to an abducted position, and an additional decrease when moving the leg into an abducted and externally rotated position. There was also a statistically significant increase in the size of the femoral vein with each of these positions. CONCLUSIONS: Up to 95% of people have some degree of overlap of the femoral vein by the femoral artery. By positioning the leg in an abducted and externally rotated position, the amount of overlap is reduced and the diameter of the vein is increased, maximizing the percentage of the vein available for cannulation.

Evaluation of an autonomous acoustic surveying technique for grassland bird communities in Nebraska.

Monitoring trends in wildlife communities is integral to making informed land management decisions and applying conservation strategies. Birds inhabit most niches in every environment and because of this they are widely accepted as an indicator species for environmental health. Traditionally, point counts are the common method to survey bird populations, however, passive acoustic monitoring approaches using autonomous recording units have been shown to be cost-effective alternatives to point count surveys. Advancements in automatic acoustic classification technologies, such as BirdNET, can aid in these efforts by quickly processing large volumes of acoustic recordings to identify bird species. While the utility of BirdNET has been demonstrated in several applications, there is little understanding of its effectiveness in surveying declining grassland birds. We conducted a study to evaluate the performance of BirdNET to survey grassland bird communities in Nebraska by comparing this automated approach to point count surveys. We deployed ten autonomous recording units from March through September 2022: five recorders in row-crop fields and five recorders in perennial grassland fields. During this study period, we visited each site three times to conduct point count surveys. We compared focal grassland bird species richness between point count surveys and the autonomous recording units at two different temporal scales and at six different confidence thresholds. Total species richness (focal and non-focal) for both methods was also compared at five different confidence thresholds using species accumulation curves. The results from this study demonstrate the usefulness of BirdNET at estimating long-term grassland bird species richness at default confidence scores, however, obtaining accurate abundance estimates for uncommon bird species may require validation with traditional methods.

hglobal-Index: A Novel Author-Level Measure of the Diffusion of Scientific Ideas Among High-, Low-, and Middle-Income Countries.

OBJECTIVE: To describe an intuitive and useful method for measuring the global impact of a medical scholar's research ideas by examining cross-border citations (CBCs) of peer-reviewed neurosurgical publications. METHODS: Publication and citation data for a random sample of the top 50 most academically productive neurosurgeons were obtained from Scopus Application Programming Interface. We characterized an author-level global impact index analogous to the widely used h-index, the hglobal-index, defined as the number of published peer-reviewed manuscripts with at least the same number of CBCs. To uncover socioeconomic insights, we explored the hglobal-index for high-, middle-, and low-income countries. RESULTS: The median (interquartile range) number of publications and CBCs were 144 (62-255) and 2704 (959-5325), respectively. The median (interquartile range) h-index and hglobal-index were 42 (23-61) and 32 (17-38), respectively. Compared with neurosurgeons in the random sample, the 3 global neurosurgeons had the highest hglobal-indices in low-income countries at 17, 13, and 9, despite below-average h-index scores of 33, 38, and 19, respectively. CONCLUSION: This intuitive update to the h-index uses CBCs to measure the global impact of scientific research. The hglobal-index may provide insight into global diffusion of medical ideas, which can be used for social science research, author self-assessment, and academic promotion.

Clinical Implications of Pituitary Adenomas Exhibiting Dual Transcription Factor Staining: A Case Series of 27 Patients.

OBJECTIVE: According to the 2017 World Health Organization classification of neuro-endocrine tumors, pituitary adenomas (PAs) are classified according to immunoexpression of the pituitary-specific transcription factors (TFs). A small subset of PAs exhibit multiple TF staining on immunohistochemistry and we present a series of 27 pathologically-confirmed cases of dual TF staining PAs (dsTF-PAs), and report clinically relevant implications. METHODS: A retrospective chart review of a multi-institutional database of patients with PAs surgically resected between 2008-2021 was performed. PAs expressing immunopositivity 2+ TFs. Patient demographics, neuro-imaging characteristics, histopathologic findings, and clinical data were collected. RESULTS: Twenty-seven patients had pathologically verified dsTF-PAs, of whom 17 were female (63%), with ages ranging from 20-84 years. Twenty-three (85.2%) patients harbored functional PAs, with acromegaly being the most common functional subtype (86.4%). The most common combination of TFs within a single tumor was PIT-1/SF-1 (85.2%). Six PAs exhibited Knosp cavernous sinus invasion grades of 3 or 4 and the Ki-67 labeling index was ≥3% in 6 patients (24.0%) and all stained for PIT-1/SF-1. Hormonal remission was achieved in 78% of functional dsTF-PAs. No PAs showed evidence of recurrence or progression over the mean follow-up period of 28.5 months. CONCLUSIONS: PAs exhibiting dsTF-PAs represent a small but clinically relevant diagnostic subset of PAs according to the 2021 World Health Organization criteria, as a majority are GH-producing. Precise classification using TF staining plays a key role in understanding the biology of these tumors. Favorable outcomes can be achieved in this subset of PAs with evolving TF classification.

A proposed clinical classification for pituitary neoplasms to guide therapy and prognosis.

No comprehensive classification system that guides prognosis and therapy of pituitary adenomas exists. The 2022 WHO histopathology-based classification system can only be applied to lesions that are resected, which represent few clinically significant pituitary adenomas. Many factors independent of histopathology provide mechanistic insight into causation and influence prognosis and treatment of pituitary adenomas. We propose a new approach to guide prognosis and therapy of pituitary adenomas by integrating clinical, genetic, biochemical, radiological, pathological, and molecular information for all adenomas arising from anterior pituitary cell lineages. The system uses an evidence-based scoring of risk factors to yield a cumulative score that reflects disease severity and can be used at the bedside to guide pituitary adenoma management. Once validated in prospective studies, this simple manageable classification system could provide a standardised platform for assessing disease severity, prognosis, and effects of therapy on pituitary adenomas.