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Pediatr Radiol ; 50(4): 543-549, 2020 Apr.
Article En | MEDLINE | ID: mdl-31840188

BACKGROUND: In the medicolegal literature, focal concavities or notching of the corpus callosum has been thought to be associated with fetal alcohol spectrum disorders. Recent work suggests corpus callosum notching is a dynamic and normal anatomical feature, although it has not yet been defined in early life or infancy. OBJECTIVE: Our purpose was to characterize the dorsal contour of the corpus callosum during the first 2 years of life by defining the prevalence, onset and trajectory of notching on midsagittal T1-weighted images. MATERIALS AND METHODS: We reviewed retrospectively 1,157 consecutive patients between birth and 2 years of age. Corpus callosum morphology was evaluated and described. A notch was defined as a dorsal concavity of at least 1 mm in depth along the dorsal surface of the corpus callosum. Patient age as well as notch depth, location, number and presence of the pericallosal artery in the notch were noted. RESULTS: Two hundred thirty-three notches were identified in 549 patients: 36 anterior, 194 posterior and 3 patients with undulations. A statistically significant (R2=0.53, Beta=0.021, P=0.002) positive correlation between posterior notch prevalence and age in months was noted. A positive correlation between age and depth of the posterior notch was also statistically significant (r=0.32, n=179, P≤0.001). A trend for increased anterior notch prevalence with age was identified with significant correlation between visualized pericallosal artery indentation and anterior notching (r=0.20, n=138, P=0.016). Sub-analysis of the first month of life showed corpus callosum notching was not present. CONCLUSION: The presence of posterior notching increased significantly with age and was more frequent than that of anterior notching. Corpus callosum notching was absent in the first week of life, building on prior studies suggesting corpus callosum notching is acquired. This study provides baseline data on normative corpus callosum notching trajectories by age group during early life, a helpful correlate when associating corpus callosum morphology with disease.

Biosensors (Basel) ; 9(2)2019 May 14.
Article En | MEDLINE | ID: mdl-31091776

In the developing world, the identification of clean, potable water continues to pose a pervasive challenge, and waterborne diseases due to fecal contamination of water supplies significantly threaten public health. The ability to efficiently monitor local water supplies is key to water safety, yet no low-cost, reliable method exists to detect contamination quickly. We developed an in vitro assay utilizing an odorant-binding protein (OBP), AgamOBP1, from the mosquito, Anopheles gambiae, to test for the presence of a characteristic metabolite, indole, from harmful coliform bacteria. We demonstrated that recombinantly expressed AgamOBP1 binds indole with high sensitivity. Our proof-of-concept assay is fluorescence-based and demonstrates the usefulness of insect OBPs as detector elements in novel biosensors that rapidly detect the presence of bacterial metabolic markers, and thus of coliform bacteria. We further demonstrated that rAgamOBP1 is suitable for use in portable, inexpensive "dipstick" biosensors that improve upon lateral flow technology since insect OBPs are robust, easily obtainable via recombinant expression, and resist detector "fouling." Moreover, due to their wide diversity and ligand selectivity, insect chemosensory proteins have other biosensor applications for various analytes. The techniques presented here therefore represent platform technologies applicable to various future devices.

Biosensing Techniques/methods , Insect Proteins/metabolism , Receptors, Odorant/metabolism , Water Quality , Animals , Anopheles/chemistry , Indoles/analysis , Insect Proteins/chemistry , Insect Proteins/genetics , Receptors, Odorant/chemistry , Receptors, Odorant/genetics , Recombinant Proteins/chemistry , Recombinant Proteins/genetics , Recombinant Proteins/metabolism
BMC Musculoskelet Disord ; 20(1): 55, 2019 Feb 08.
Article En | MEDLINE | ID: mdl-30736775

BACKGROUND: Wearables consist of numerous technologies that are worn on the body and measure parameters such as step count, distance travelled, heart rate and sleep quantity. Recently, various wearable systems have been designed capable of detecting spinal posture and providing live biofeedback when poor posture is sustained. It is hypothesised that long-term use of these wearables may improve spinal posture. RESEARCH QUESTIONS: To (1) examine the capabilities of current devices assessing spine posture, (2) to identify studies implementing such devices in the clinical setting and (3) comment on the clinical practicality of integration of such devices into routine care where appropriate. METHODS: A comprehensive systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA) across the following databases: PubMed; MEDLINE; EMBASE; Cochrane; and Scopus. Articles related to wearables systems able to measure spinal posture were selected amongst all published studies dated from 1980 onwards. Extracted data was collected as per a predetermined checklist including device types, study objectives, findings and limitations. RESULTS: A total of 37 articles were extensively reviewed and analysed in the final review. The proposed wearables most commonly used Inertial Measurement Units (IMUs) as the underlying technology. Wearables measuring spinal posture have been proposed to be used in the following settings: post-operative rehabilitation; treatment of musculoskeletal disorders; diagnosis of pathological spinal posture; monitoring of progression of Parkinson's Disease; detection of falls; workplace occupational health and safety; comparison of interventions. CONCLUSIONS: This is the first and only study to specifically review wearable devices that monitor spinal posture. Our findings suggest that currently available devices are capable of assessing spinal posture with good accuracy in the clinical setting. However, further validation regarding the long-term use of these technologies and improvements regarding practicality is required for commercialisation.

Biofeedback, Psychology/instrumentation , Posture , Spine/physiopathology , Wearable Electronic Devices , Equipment Design , Humans , Predictive Value of Tests , Recovery of Function , Treatment Outcome
Nat Med ; 24(12): 1941, 2018 Dec.
Article En | MEDLINE | ID: mdl-30361510

In the version of this article originally published, there was an error in Fig. 2b. RECIST ORR and pCR were both listed as 25%. RECIST ORR was actually 73%, and pCR was 45%. Also, an author's name was incorrect in the author list. Danny K. Wells should have been listed as Daniel K. Wells. The errors have been corrected in the print, HTML and PDF versions of this article.

Nat Med ; 24(12): 1942, 2018 Dec.
Article En | MEDLINE | ID: mdl-30361511

In the version of this article originally published, there was an error in Fig. 1. In the neoadjuvant phase column, the n values for arms A and B were both reported to be 20. The n values for arms A and B were actually 12 and 11, respectively. Also, the URL underlying the accession code in the data availability section was incorrect. The URL was originally It should have been The errors have been corrected in the print, HTML and PDF versions of this article.

Nat Med ; 24(11): 1649-1654, 2018 11.
Article En | MEDLINE | ID: mdl-30297909

Preclinical studies suggest that treatment with neoadjuvant immune checkpoint blockade is associated with enhanced survival and antigen-specific T cell responses compared with adjuvant treatment1; however, optimal regimens have not been defined. Here we report results from a randomized phase 2 study of neoadjuvant nivolumab versus combined ipilimumab with nivolumab in 23 patients with high-risk resectable melanoma ( NCT02519322 ). RECIST overall response rates (ORR), pathologic complete response rates (pCR), treatment-related adverse events (trAEs) and immune correlates of response were assessed. Treatment with combined ipilimumab and nivolumab yielded high response rates (RECIST ORR 73%, pCR 45%) but substantial toxicity (73% grade 3 trAEs), whereas treatment with nivolumab monotherapy yielded modest responses (ORR 25%, pCR 25%) and low toxicity (8% grade 3 trAEs). Immune correlates of response were identified, demonstrating higher lymphoid infiltrates in responders to both therapies and a more clonal and diverse T cell infiltrate in responders to nivolumab monotherapy. These results describe the feasibility of neoadjuvant immune checkpoint blockade in melanoma and emphasize the need for additional studies to optimize treatment regimens and to validate putative biomarkers.

Ipilimumab/administration & dosage , Melanoma/drug therapy , Neoadjuvant Therapy , Nivolumab/administration & dosage , Adult , Antineoplastic Combined Chemotherapy Protocols/administration & dosage , Disease-Free Survival , Drug-Related Side Effects and Adverse Reactions/classification , Drug-Related Side Effects and Adverse Reactions/pathology , Female , Humans , Male , Melanoma/immunology , Melanoma/pathology , Melanoma/surgery , Middle Aged , Neoplasm Staging , Risk Factors
Asian Spine J ; 12(3): 446-458, 2018 Jun.
Article En | MEDLINE | ID: mdl-29879772

STUDY DESIGN: A literature review. PURPOSE: To explore the utility of laminoplasty in combination with instrumented fusion, with a focus on neurological outcomes and changes in kyphotic deformity. OVERVIEW OF LITERATURE: Management of cervical spondylotic myelopathy (CSM) to reduce morbidity within the neurosurgical population. METHODS: A US National Library of Medicine PubMed search was conducted for manuscripts pertaining to cervical laminoplasty and fusion for the management of CSM. Several relevant studies were shortlisted for review, and the bibliographies of the articles were searched for additional references. The search was limited to human studies, English-language literature, and reports on more than one patient. RESULTS: Combined laminoplasty and fusion was found to provide at least comparable, if not superior, neurological outcomes in specific patient populations with CSM. The Japanese Orthopedic Association scores, local kyphosis, and C2-C7 angle have been reviewed in several manuscripts, and improvement in each of these categories was found with laminoplasty and fusion. CONCLUSIONS: The treatment of CSM necessitates an individualized approach based on the pathoanatomical variation. Laminoplasty and fusion can be appropriately used for patients with CSM in a setting of local kyphotic deformity, ossification of the posterior longitudinal ligament, associated segmental instability, and the need for strong stabilization.

Lancet Oncol ; 19(2): 181-193, 2018 02.
Article En | MEDLINE | ID: mdl-29361468

BACKGROUND: Dual BRAF and MEK inhibition produces a response in a large number of patients with stage IV BRAF-mutant melanoma. The existing standard of care for patients with clinical stage III melanoma is upfront surgery and consideration for adjuvant therapy, which is insufficient to cure most patients. Neoadjuvant targeted therapy with BRAF and MEK inhibitors (such as dabrafenib and trametinib) might provide clinical benefit in this high-risk p opulation. METHODS: We undertook this single-centre, open-label, randomised phase 2 trial at the University of Texas MD Anderson Cancer Center (Houston, TX, USA). Eligible participants were adult patients (aged ≥18 years) with histologically or cytologically confirmed surgically resectable clinical stage III or oligometastatic stage IV BRAFV600E or BRAFV600K (ie, Val600Glu or Val600Lys)-mutated melanoma. Eligible patients had to have an Eastern Cooperative Oncology Group performance status of 0 or 1, a life expectancy of more than 3 years, and no previous exposure to BRAF or MEK inhibitors. Exclusion criteria included metastases to bone, brain, or other sites where complete surgical excision was in doubt. We randomly assigned patients (1:2) to either upfront surgery and consideration for adjuvant therapy (standard of care group) or neoadjuvant plus adjuvant dabrafenib and trametinib (8 weeks of neoadjuvant oral dabrafenib 150 mg twice per day and oral trametinib 2 mg per day followed by surgery, then up to 44 weeks of adjuvant dabrafenib plus trametinib starting 1 week after surgery for a total of 52 weeks of treatment). Randomisation was not masked and was implemented by the clinical trial conduct website maintained by the trial centre. Patients were stratified by disease stage. The primary endpoint was investigator-assessed event-free survival (ie, patients who were alive without disease progression) at 12 months in the intent-to-treat population. This trial is registered at, number NCT02231775. FINDINGS: Between Oct 23, 2014, and April 13, 2016, we randomly assigned seven patients to standard of care, and 14 to neoadjuvant plus adjuvant dabrafenib and trametinib. The trial was stopped early after a prespecified interim safety analysis that occurred after a quarter of the participants had been accrued revealed significantly longer event-free survival with neoadjuvant plus adjuvant dabrafenib and trametinib than with standard of care. After a median follow-up of 18·6 months (IQR 14·6-23·1), significantly more patients receiving neoadjuvant plus adjuvant dabrafenib and trametinib were alive without disease progression than those receiving standard of care (ten [71%] of 14 patients vs none of seven in the standard of care group; median event-free survival was 19·7 months [16·2-not estimable] vs 2·9 months [95% CI 1·7-not estimable]; hazard ratio 0·016, 95% CI 0·00012-0·14, p<0·0001). Neoadjuvant plus adjuvant dabrafenib and trametinib were well tolerated with no occurrence of grade 4 adverse events or treatment-related deaths. The most common adverse events in the neoadjuvant plus adjuvant dabrafenib and trametinib group were expected grade 1-2 toxicities including chills (12 patients [92%]), headache (12 [92%]), and pyrexia (ten [77%]). The most common grade 3 adverse event was diarrhoea (two patients [15%]). INTERPRETATION: Neoadjuvant plus adjuvant dabrafenib and trametinib significantly improved event-free survival versus standard of care in patients with high-risk, surgically resectable, clinical stage III-IV melanoma. Although the trial finished early, limiting generalisability of the results, the findings provide proof-of-concept and support the rationale for further investigation of neoadjuvant approaches in this disease. This trial is currently continuing accrual as a single-arm study of neoadjuvant plus adjuvant dabrafenib and trametinib. FUNDING: Novartis Pharmaceuticals Corporation.

Imidazoles/administration & dosage , Melanoma/drug therapy , Melanoma/mortality , Oximes/administration & dosage , Pyridones/administration & dosage , Pyrimidinones/administration & dosage , Skin Neoplasms/drug therapy , Skin Neoplasms/mortality , Academic Medical Centers , Adult , Aged , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Cancer Care Facilities , Chemotherapy, Adjuvant/methods , Confidence Intervals , Disease-Free Survival , Humans , Melanoma/pathology , Melanoma/surgery , Middle Aged , Mohs Surgery/methods , Neoadjuvant Therapy/methods , Neoplasm Invasiveness/pathology , Neoplasm Staging , Prognosis , Risk Assessment , Skin Neoplasms/pathology , Skin Neoplasms/surgery , Standard of Care , Survival Analysis , Texas , Treatment Outcome
J Neurosurg Pediatr ; 18(2): 164-70, 2016 Aug.
Article En | MEDLINE | ID: mdl-27058457

OBJECTIVE The Thoracolumbar Injury Classification and Severity Score (TLICS) system was developed to streamline injury assessment and guide surgical decision making. To the best of the authors' knowledge, external validation in the pediatric age group has not been undertaken prior to this report. METHODS This study evaluated the use of the TLICS in a large retrospective series of children and adolescents treated at 4 pediatric medical centers (Texas Children's Hospital, Children's Healthcare of Atlanta, Riley Children's Hospital, and Doernbecher Children's Hospital). A total of 147 patients treated for traumatic thoracic or lumbar spine trauma between February 1, 2002, and September 1, 2015, were included in this study. Clinical and radiographic data were evaluated. Injuries were classified using American Spinal Injury Association (ASIA) status, Denis classification, and TLICS. RESULTS A total of 102 patients (69%) were treated conservatively, and 45 patients (31%) were treated surgically. All patients but one in the conservative group were classified as ASIA E. In this group, 86/102 patients (84%) had Denis type compression injuries. The TLICS in the conservative group ranged from 1 to 10 (mean 1.6). Overall, 93% of patients matched TLICS conservative treatment recommendations (score ≤ 3). No patients crossed over to the surgical group in delayed fashion. In the surgical group, 26/45 (58%) were ASIA E, whereas 19/45 (42%) had neurological deficits (ASIA A, B, C, or D). One of 45 (2%) patients was classified with Denis type compression injuries; 25/45 (56%) were classified with Denis type burst injuries; 14/45 (31%) were classified with Denis type seat belt injuries; and 5/45 (11%) were classified with Denis type fracture-dislocation injuries. The TLICS ranged from 2 to 10 (mean 6.4). Eighty-two percent of patients matched TLICS surgical treatment recommendations (score ≥ 5). No patients crossed over to the conservative management group. Eight patients (8/147, 5%) had a calculated TLICS of 4, which meant they were candidates for surgery or conservative therapy by TLICS criteria. Excluding these patients, the degree of agreement between TLICS and surgeon decision was deemed to be very good (κ = 0.878). CONCLUSIONS The TLICS results and recommendations matched treatment in 96% of conservative group cases. In the surgical group, TLICS recommendations matched treatment in 93% of cases. The TLICS recommendations and surgeon decision making displayed very good concordance. The TLICS appears to be effective in the classification of thoracic and lumbar spine injuries and in guiding treatment in the pediatric age group.

Injury Severity Score , Lumbar Vertebrae/injuries , Spinal Cord Injuries/classification , Spinal Cord Injuries/diagnosis , Thoracic Vertebrae/injuries , Adolescent , Child , Child, Preschool , Female , Follow-Up Studies , Humans , Infant , Male , Reproducibility of Results , Retrospective Studies
JAMA Oncol ; 2(8): 1056-64, 2016 Aug 01.
Article En | MEDLINE | ID: mdl-27124486

IMPORTANCE: Combined treatment with dabrafenib and trametinib (CombiDT) achieves clinical responses in only about 15% of patients with BRAF inhibitor (BRAFi)-refractory metastatic melanoma in contrast to the higher response rate observed in BRAFi-naïve patients. Identifying correlates of response and mechanisms of resistance in this population will facilitate clinical management and rational therapeutic development. OBJECTIVE: To determine correlates of benefit from CombiDT therapy in patients with BRAFi-refractory metastatic melanoma. DESIGN, SETTING, AND PARTICIPANTS: Single-center, single-arm, open-label phase 2 trial of CombiDT treatment in patients with BRAF V600 metastatic melanoma resistant to BRAFi monotherapy conducted between September 2012 and October 2014 at the University of Texas MD Anderson Cancer Center. Key eligibility criteria for participants included BRAF V600 metastatic melanoma, prior BRAFi monotherapy, measurable disease (RECIST 1.1), and tumor accessible for biopsy. INTERVENTIONS: Patients were treated with dabrafenib (150 mg, twice daily) and trametinib (2 mg/d) continuously until disease progression or intolerance. All participants underwent a mandatory baseline biopsy, and optional biopsy specimens were obtained on treatment and at disease progression. Whole-exome sequencing, reverse transcription polymerase chain reaction analysis for BRAF splicing, RNA sequencing, and immunohistochemical analysis were performed on tumor samples, and blood was analyzed for levels of circulating BRAF V600. MAIN OUTCOMES AND MEASURES: The primary end point was overall response rate (ORR). Progression-free survival (PFS) and overall survival (OS) were secondary clinical end points. RESULTS: A total of 28 patients were screened, and 23 enrolled. Among evaluable patients, the confirmed ORR was 10%; disease control rate (DCR) was 45%, and median PFS was 13 weeks. Clinical benefit was associated with duration of prior BRAFi therapy greater than 6 months (DCR, 73% vs 11% for ≤6 months; P = .02) and decrease in circulating BRAF V600 at day 8 of cycle 1 (DCR, 75% vs 18% for no decrease; P = .02) but not with pretreatment mitogen-activated protein kinase (MAPK) pathway mutations or activation. Biopsy specimens obtained during treatment demonstrated that CombiDT therapy failed to achieve significant MAPK pathway inhibition or immune infiltration in most patients. CONCLUSIONS AND RELEVANCE: The baseline presence of MAPK pathway alterations was not associated with benefit from CombiDT in patients with BRAFi-refractory metastatic melanoma. Failure to inhibit the MAPK pathway provides a likely explanation for the limited clinical benefit of CombiDT in this setting. Circulating BRAF V600 is a promising early biomarker of clinical response. TRIAL REGISTRATION: Identifier: NCT01619774.

Antineoplastic Agents/therapeutic use , MAP Kinase Signaling System/genetics , Melanoma/drug therapy , Protein Kinase Inhibitors/therapeutic use , Skin Neoplasms/drug therapy , Adaptor Proteins, Signal Transducing/metabolism , Adult , B7-H1 Antigen/metabolism , CD8 Antigens/metabolism , Disease-Free Survival , Drug Resistance, Neoplasm , Female , Humans , Imidazoles/administration & dosage , Immunohistochemistry , Male , Melanoma/genetics , Melanoma/immunology , Melanoma/secondary , Middle Aged , Mitogen-Activated Protein Kinase 1/metabolism , Mitogen-Activated Protein Kinase 3/metabolism , Mitogen-Activated Protein Kinases/genetics , Mitogen-Activated Protein Kinases/metabolism , Oximes/administration & dosage , Phosphorylation , Prospective Studies , Proto-Oncogene Proteins B-raf/antagonists & inhibitors , Proto-Oncogene Proteins B-raf/genetics , Proto-Oncogene Proteins B-raf/metabolism , Pyridones/administration & dosage , Pyrimidinones/administration & dosage , Ribosomal Protein S6/metabolism , Signal Transduction , Skin Neoplasms/genetics , Skin Neoplasms/immunology , Skin Neoplasms/pathology , Treatment Outcome
J Neurosurg ; 121(6): 1526-32, 2014 Dec.
Article En | MEDLINE | ID: mdl-25216067

OBJECT: In Tanzania, there are 4 neurosurgeons for a population of 46 million. To address this critical shortage of neurosurgical care, the authors worked with local Tanzanian health care workers, neurosurgeons, the Ministry of Health and Social Welfare, and the Office of the President of Tanzania to develop a train-forward method for sustainable, self-propagating basic and emergency neurosurgery in resource-poor settings. The goal of this study was to assess the safety and effectiveness of this method over a 6-year period. METHODS: The training method utilizes a hands-on bedside teaching technique and was introduced in 2006 at a remote rural hospital in northern Tanzania. Local health care workers were trained to perform basic and emergency neurosurgical procedures independently and then were taught to train others. Outcome information was retrospectively collected from hospital records for the period from 2005 (1 year before method implementation) through 2010. Analysis of de-identified data included descriptive statistics and multivariable assessment of independent predictors of complications following a patient's first neurosurgical procedure. RESULTS: By 2010, the initial Tanzanian trainee had trained a second Tanzanian health care worker, who in turn had trained a third. The number of neurosurgical procedures performed increased from 18 in 2005 to an average of 92 per year in the last 3 years of the study period. Additionally, the number of neurosurgical cases performed independently by Tanzanian health care providers increased significantly from 44% in 2005 to 86% in 2010 (p < 0.001), with the number of complex cases independently performed also increasing over the same time period from 34% to 83% (p < 0.001). Multivariable analysis of clinical patient outcome information to assess safety indicated that postoperative complications decreased significantly from 2005 through 2010, with patients who had been admitted as training progressed being 29% less likely to have postoperative complications (OR 0.71, 95% CI 0.52-0.96, p = 0.03). CONCLUSIONS: The Madaktari Africa train-forward method is a reasonable and sustainable approach to improving specialized care in a resource-poor setting.

Capacity Building/methods , Education, Medical, Graduate/methods , Neurosurgery/education , Rural Health Services , Adolescent , Adult , Capacity Building/organization & administration , Developing Countries , Education, Medical, Graduate/statistics & numerical data , Female , Health Services Accessibility/organization & administration , Health Services Accessibility/statistics & numerical data , Humans , Male , Rural Health Services/organization & administration , Rural Health Services/statistics & numerical data , Social Welfare , Tanzania , Workforce , Young Adult
J Shoulder Elbow Surg ; 21(10): 1278-88, 2012 Oct.
Article En | MEDLINE | ID: mdl-22265767

BACKGROUND: Hemiarthroplasty (humeral head replacement [HHR]) and reverse shoulder arthroplasty (RSA) are surgical options for cuff tear arthropathy (CTA). RSA may provide better pain relief and functional outcomes, but it costs more and may have a higher complication rate. The goal of this study was to compare the cost-effectiveness of these two treatments and to use sensitivity analysis to determine the drivers of the model. MATERIALS AND METHODS: A Markov decision model was used. Outcome and complication probabilities were obtained from existing literature. Costs were based on average Medicare reimbursement and implant prices. Utilities were derived from responses to health state surveys (Short Form 6D) from 31 patients at one institution who underwent RSA or HHR for CTA. Incremental cost-effectiveness ratios were used to compare treatments. RESULTS: Our model showed RSA could be a cost-effective strategy for treatment of CTA, using $100,000 per quality-adjusted life-year gained as a cutoff and the Short Form 6D for utilities. The model was extremely sensitive to the complication rate and the utility of each procedure and was also sensitive to implant price, with an implant price <$13,000 making RSA cost-effective. CONCLUSIONS: Currently available cost and outcome data show that RSA could be a cost-effective alternative to HHR for CTA. The cost-effectiveness of RSA depends most on the health utility gained from the operation, the utility lost due to complications from the operation, and the cost of the implant. Dropping the implant price to <$7,000 increases cost-effectiveness to <$50,000 per quality-adjusted life-year gained. Further head-to-head studies evaluating the clinical and quality of life outcomes of these two treatments are warranted.

Arthroplasty, Replacement/economics , Hemiarthroplasty/economics , Lacerations/surgery , Shoulder Joint/surgery , Aged , Aged, 80 and over , Arthroplasty, Replacement/methods , Cost-Benefit Analysis , Hemiarthroplasty/methods , Humans , Lacerations/complications , Middle Aged , Range of Motion, Articular , Retrospective Studies , Rotator Cuff/surgery , Rupture/diagnosis , Rupture/surgery , Shoulder Joint/physiopathology , Time Factors , Treatment Outcome
Neurosurgery ; 70(4): E1049-52; discussion E1052, 2012 Apr.
Article En | MEDLINE | ID: mdl-21788916

BACKGROUND AND IMPORTANCE: Paragangliomas are rare tumors of neuroendocrine origin that arise from paraganglionic tissue of the extrachromaffin cell system. These lesions may be seen at various sites along the neuraxis. Primary thoracic paragangliomas have rarely been reported in the literature, with secretory thoracic lesions being exceedingly rare as only 3 previous cases have been cited. CLINICAL PRESENTATION: A 49-year-old woman presented with episodes of hypertension, palpitations, and diaphoresis. Workup revealed positive urine catecholamines and a thoracic spine mass extending into the thoracic apex. Preoperative α-blockade with phenoxybenzamine was used followed by posterior decompression and tumor resection. Arthrodesis from C5 to T4 was subsequently performed, and the patient received postoperative radiation. CONCLUSION: Two years postoperatively, the patient has continued to have regression of her symptoms. We report a rare case of a catecholamine-secreting primary thoracic paraganglioma in a 49-year-old woman. These tumors should be treated carefully by the neurosurgeon with preoperative assistance from endocrinology for α-blockade, followed by gross total resection and postoperative radiation if residual tumor remains.

Catecholamines/metabolism , Paraganglioma, Extra-Adrenal/metabolism , Paraganglioma, Extra-Adrenal/pathology , Spinal Neoplasms/metabolism , Spinal Neoplasms/pathology , Decompression, Surgical , Female , Humans , Middle Aged , Paraganglioma, Extra-Adrenal/surgery , Spinal Neoplasms/surgery , Thoracic Vertebrae
Neurosurgery ; 69(4): E995-9, 2011 Oct.
Article En | MEDLINE | ID: mdl-21572359

BACKGROUND AND IMPORTANCE: To report a rare case of spinal intradural extraosseous Ewing sarcoma in an adult and review current literature. Although Ewing sarcoma belongs to the family, the treatment modalities are different, and thus the correct diagnosis is very important despite its rare occurrence. CLINICAL PRESENTATION: A 56-year-old woman presented with nocturnal bilateral buttock and leg pain. Magnetic resonance imaging (MRI) showed an enhancing intradural extramedullary extraosseous tumor at L1. INTERVENTION: A T12-L2 laminectomy was performed to resect the tumor. Immunohistochemical analysis confirmed the diagnosis of Ewing sarcoma. A thorough diagnostic workup did not reveal any bony origin of the tumor. Primary intradural central nervous system Ewing sarcoma is infrequently encountered and shares imaging and histopathological features with central primitive neuroectodermal tumors. Establishment of the right diagnosis is crucial because it mandates a distinct workup and treatment modality different from that for central primitive neuroectodermal tumor. Although osseous Ewing sarcoma predominantly occurs in children and young adults, extraosseous central nervous system Ewing sarcoma is not uncommon in adults and should therefore be considered in the differential diagnosis of extraosseous small blue cell tumors in adult patients.

Sarcoma, Ewing/pathology , Spinal Cord Neoplasms/pathology , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Combined Modality Therapy , Female , Humans , Immunohistochemistry , Laminectomy , Lumbar Vertebrae , Magnetic Resonance Imaging , Middle Aged , Radiotherapy , Sarcoma, Ewing/therapy , Spinal Cord Neoplasms/therapy