Stent-assisted Woven EndoBridge embolization for the treatment of pulsatile tinnitus caused by an ipsilateral high-riding jugular bulb.

PURPOSE: Pulsatile tinnitus can be caused by a high-riding jugular bulb (HRJB), characterized by the superior position of the jugular bulb in the petrous temporal bone. The anatomical position and morphology of this entity make it challenging for endovascular treatment. We report our experience with two patients successfully treated with a stent-assisted Woven EndoBridge (WEB; Microvention, Tustin, CA, USA) device. MATERIALS AND METHODS: We describe two cases of HRJB in patients presenting with disabling pulsatile tinnitus. Temporary balloon occlusion of the jugular bulb prior to the intervention reduced tinnitus intensity. Both patients were subsequently treated under general anesthesia with the WEB device deployed in the HRJB which was held by a stent deployed in the sigmoid sinus. RESULTS: Both procedures were successful with good positioning of the WEB device and no procedural complications. Both patients had complete resolution of pulsatile tinnitus immediately after the procedure. Follow-up imaging showed successful occlusion of the venous cavity with a widely patent stent. CONCLUSION: Among patients with pulsatile tinnitus caused by an ipsilateral HRJB, a stent-assisted WEB device seems to be a viable endovascular option with angiographic and clinical success.

Exploring Medical Students' Perceptions of Peer-to-Peer Interactions Related to Applying to a Surgical Residency.

OBJECTIVE: The objectives were to (1) identify themes related to competitive peer-to-peer interactions elicited from the lived experiences of undergraduate medical students, and (2) understand how these experiences influenced medical students' choices related to surgical residency programs. DESIGN: A qualitative descriptive methodology, with purposive and maximal variation sampling (e.g., selection based on medical school location; gender), was adopted for this study. SETTING: Temerty Faculty of Medicine, University of Toronto. PARTICIPANTS: Participants were 15 undergraduate medical students from 4 medical schools in Ontario, Canada, who agreed to an individual semi-structured interview by Zoom or telephone. RESULTS: Peer-to-peer interactions influence students' perception of self and identity formation related to surgical specialty decision-making and interest. These interactions were shown to hold greater value, specifically for information gathering. Identity formation, related to pursuing a surgical residency, was influenced by the attitudes and perceptions of competition with peers throughout medical school. Cultures of competition were seen to dictate peer-to-peer interactions and their associated value, with their perception and experience differing between medical schools. CONCLUSIONS: Peer-to-peer interactions and a culture of competition have inherent roles in the residency decision-making process. We observed that student background and pre-formed relationships influenced how students perceived and responded to competition. Addressing the culture of competitiveness associated with peer-to-peer interactions along with considering student background and pre-existing relationships may provide insight into how medical educators can tailor learning experiences that limit the detrimental effects of hidden curriculum influences.

Meningeal metastases in prostate cancer: Institutional series and comprehensive systematic review.

Meningeal metastases (MM) are a rare progression in advanced prostate. Here we aimed to characterize the incidence, clinical presentation, and outcomes of patients with MM, including dural and leptomeningeal metastases, from primary prostate cancer. A systematic search was performed on MEDLINE, EMBASE, Scopus, and Web of Science. Studies that included patients who developed MM from primary prostate cancer were abstracted. Assessed outcomes included time from primary cancer to MM and MM to death, and clinical presentation of MM, among others. Case reports were compared qualitatively, while observational studies were pooled for quantitative synthesis. The systematic review was prospectively registered on PROSPERO (CRD42020205378). Our institutional series, 11 observational studies, and 46 case reports were synthesized, comprising a total of 191 patients. From the observational studies, the mean age at developing MM was 63.0 years (range: 58.4, 70.9). Presenting neurological symptoms were variable and largely depended on location of MM. The mean time from prostate cancer to MM was 54.6 months (range: 21.0, 101.5), and the mean time from MM to death was 9.0 months (range: 2.6, 23.0). Patients requiring resection for MM had shorter survival after disease progression compared to patients receiving radiation or supportive therapy. All articles had at least moderate risk of bias. We describe the largest synthesis of patients with progression to MM from prostate cancer. Current evidence is very low-quality and primarily stems from small observational studies. Neurological symptoms in the setting of advanced prostate cancer, especially in high-risk disease, warrants radiographic imaging for MM. Further prospective research on risk factors and treatment for MM is warranted.

The Association of Frailty with Outcomes after Cancer Surgery: A Systematic Review and Metaanalysis.

BACKGROUND: Cancer is common in older adults, who often have concurrent frailty. Frailty is a strong predictor of adverse outcomes in surgical patients. Our objective is to systematically review the association of frailty with postoperative mortality and other adverse outcomes in adult patients who have undergone nonemergency cancer surgery. METHODS: After registration (CRD42020171163), we systematically reviewed PubMed, MEDLINE, EMBASE, and CINAHL databases to identify all studies reporting an association between a preoperative frailty measurement and a relevant outcome (primary: all-cause mortality in-hospital or within 30 days of surgery; secondary outcomes: postoperative complications, length of stay, discharge disposition, mortality between 30 days and 1 year, postoperative function, and delirium). All stages of the review were completed in duplicate. Risk of bias was assessed using the Quality in Prognostic Studies (QUIPS) tool. Metaanalysis was used to pool effect estimates using random-effects models. RESULTS: A total of 2877 studies were identified, and 71 were included. Frailty was significantly associated with mortality within 30 days (adjusted odds ratio (OR) 3.02, 95% confidence interval (CI) 1.77-5.15), adverse discharge disposition (adjusted OR 2.14, 95% CI 1.52-3.02), postoperative complications (adjusted OR 2.39, 95% CI 1.64-3.49), longer-term mortality (unadjusted OR 4.32, 95% CI 2.15-8.67), and length of stay (mean difference 2.30, 95% CI 1.10-3.50). The number of studies presenting adequately adjusted estimates was small. Findings may be limited due to publication bias. CONCLUSIONS: In adults having elective cancer surgery, frailty is strongly associated with adverse health outcomes. Preoperative frailty assessment should be considered in prognostication.

Current state of therapeutic focused ultrasound applications in neuro-oncology.

INTRODUCTION: Despite manifold advances in oncology, cancers of the central nervous system remain among the most lethal. Unique features of the brain, including distinct cellular composition, immunological privilege, and physical barriers to therapeutic delivery, likely contribute to the poor prognosis of patients with neuro-oncological disease. Focused ultrasound is an emerging technology that allows transcranial delivery of ultrasound energy to focal brain targets with great precision. METHODS: A review of the clinical and preclinical focused ultrasound literature was performed to obtain data regarding the current state of the focused ultrasound in context of neuro-oncology. A narrative review was then constructed to provide an overview of current and future applications of this technology. RESULTS: Focused ultrasound can facilitate direct control of tumors by thermal or mechanical ablation, as well as enhance delivery of diverse therapeutics by disruption of the blood-brain barrier without local tissue damage. Indeed, ultrasound-sensitive drug formulations or sonosensitizers may be combined with ultrasound blood-brain barrier disruption to achieve high local drug concentration while limiting systemic exposure to therapeutics. Furthermore, focused ultrasound can induce radiosensitization, immunomodulation, and neuromodulation. Here we review applications of focused ultrasound with a focus on approaches currently under clinical investigation for the treatment of neuro-oncological disease, such as blood-brain barrier disruption for drug delivery and thermal ablation. We also discuss design of clinical trials, selection of patient cohorts, and emerging approaches to improve the efficacy of transcranial ultrasound, such as histotripsy, as well as combinatorial strategies to exploit synergistic biological effects of existing cancer therapies and ultrasound. CONCLUSIONS: Focused ultrasound is a promising and actively expanding therapeutic modality for diverse neuro-oncological diseases.