Sentinel report of uniquely paired collision tumors: glioblastoma multiforme and coexistent intraventricular subependymoma. Illustrative case.

BACKGROUND: The presence of intracranial collision tumors, histologically distinct tumors occurring in anatomical proximity, is quite rare. Herein, the authors describe the sentinel case of a contiguous collision tumor combination consisting of glioblastoma multiforme and intraventricular subependymoma. OBSERVATIONS: A 67-year-old male presented with several months of progressive fatigue superimposed on more recently noted word-finding difficulty, slight left-sided weakness, and episodic confusion. He was found to have a large right frontal mass abutting the right lateral ventricle with an additional nodular focus of enhancement within the right frontal horn. The patient underwent an awake right frontal craniotomy for gross-total resection of the tumor, noted to be of two distinct histological identities. LESSONS: Although exceptionally rare, primary glial neoplasms of various histologies can be encountered simultaneously during resection, as in this case of co-occurring glioblastoma of the right frontal lobe and right frontal horn intraventricular subependymoma. Close attention to tumoral locations and the gross appearance of specimens during resection can prime the operative neurosurgeon for success in contributing to accurate diagnoses through sending separate pathological specimens for histological analysis when qualitatively different tissue is suspected.

Genomic testing in voluntary workplace wellness programs in the US: Evidence and challenges.

BACKGROUND: Workplace genetic and/or genomic testing (wGT) is one of many options that employers can offer within the scope of voluntary workplace wellness programs, though we know little about how many employers are offering this benefit, or what kinds of testing are included. METHODS: Our landscaping review sought to discover the prevalence and distribution of wGT within voluntary wellness programs among U.S. companies using three approaches: (1) analysis of publicly available information; (2) national surveys; and (3) interviews with company representatives. RESULTS: In total, 50/420 (11.9%) companies we investigated had publicly available data suggesting that they offer wGT to their employees. Survey data weighted to be representative of the type and distribution of U.S. companies suggest that ~1% of U.S. companies offer wGT to their employees. CONCLUSION: Our research found little evidence of broad uptake of wGT among U.S. companies, though information gathering was challenging.

Intratumoral abscess complicating a postradiation-induced World Health Organization grade II meningioma: illustrative case.

BACKGROUND: Cerebral meningiomas and brain abscesses are common independently, but intrameningioma abscesses rarely occur, with only 15 cases in the literature. These abscesses most frequently develop in patients with a known source of bacteremia; only one case of intrameningioma abscess without a known source of infection has been reported previously. OBSERVATIONS: This is the second reported case of an intrameningioma abscess without a clear source of infection, occurring in a 70-year-old female with a history of transsphenoidal craniopharyngioma resection and radiation many years prior. She presented with severe fatigue and altered mental status initially ascribed to adrenal insufficiency, and magnetic resonance imaging showed a new heterogeneously enhancing left temporal mass with surrounding edema. After urgent tumor resection, pathology demonstrated a World Health Organization grade II meningioma (radiation induced). After a course of steroids and intravenous nafcillin, the patient recovered without neurological deficits. LESSONS: The natural history of intrameningioma abscesses is not fully understood. These uncommon lesions can form secondary to hematogenous spread facilitated by meningiomas' robust vascularization, typically in patients with bacteremia. Even when no significant source of infection is identified, the differential diagnosis of intrameningioma abscess should be considered because this pathology can be rapidly progressive, even fatal, but is treatable if recognized promptly.

Cost-Savings of Do Not Resuscitate Orders Among Elderly Patients With Heart Failure in the United States.

Do-not-resuscitate (DNR) orders should preclude the use of cardiopulmonary resuscitation and may be associated with patient outcomes for patients hospitalized with heart failure (HF). This study examined the association between DNR and costs, mortality, and length of stay. The study cohort was a national sample of 700 922 hospital admissions of patients aged >65 with a primary diagnosis of HF. Elderly HF patients who died with a DNR had cost-savings of $5640 ( P < 0.001). Patients with a DNR order were 8.9% points more likely to die before discharge than patients without ( P < 0.001), and patients who died with a DNR had a significantly shorter hospital stay by 1.51 days ( P < 0.001). DNR orders among elderly patients with HF are associated with cost-savings, as well as a higher mortality and shorter length of stay. In addition to primary benefits, advance care planning may aid in containing costs of care at end of life for HF.

Enrollment of Participants From Marginalized Racial and Ethnic Groups: A Comparative Assessment of the STEADY-PD III and SURE-PD3 Trials.

Background and Objectives: Representation of persons from marginalized racial and ethnic groups in Parkinson disease (PD) trials has been low, limiting the generalizability of therapeutic options for individuals with PD. Two large phase 3 randomized clinical trials sponsored by the National Institute of Neurological Disorders and Stroke (NINDS), STEADY-PD III and SURE-PD3, screened participants from overlapping Parkinson Study Group clinical sites under similar eligibility criteria but differed in participation by underrepresented minorities. The goal of this research is to compare recruitment strategies of PD participants belonging to marginalized racial and ethnic groups. Methods: A total of 998 participants with identified race and ethnicity consented to STEADY-PD III and SURE-PD3 from 86 clinical sites. Demographics, clinical trial characteristics, and recruitment strategies were compared. NINDS imposed a minority recruitment mandate on STEADY-PD III but not SURE-PD3. Results: Ten percent of participants who consented to STEADY-PD III self-identified as belonging to marginalized racial and ethnic groups compared to 6.5% in SURE-PD3 (difference = 3.9%, 95% confidence interval [CI] 0.4%-7.5%, p value = 0.034). This difference persisted after screening (10.1% of patients in STEADY-PD III vs 5.4% in SURE-PD 3, difference = 4.7%, 95% CI 0.6%-8.8%, p value = 0.038). Discussion: Although both trials targeted similar participants, STEADY-PD III was able to consent and recruit a higher percentage of patients from racial and ethnic marginalized groups. Possible reasons include differential incentives for achieving minority recruitment goals. Trial Registration Information: This study used data from The Safety, Tolerability, and Efficacy Assessment of Isradipine for Parkinson Disease (STEADY-PD III; NCT02168842) and the Study of Urate Elevation in Parkinson's Disease (SURE-PD3; NCT02642393).

Validity of ICD codes to identify do-not-resuscitate orders among older adults with heart failure: A single center study.

BACKGROUND: Observational research on the advance care planning (ACP) process is limited by a lack of easily accessible ACP variables in many large datasets. The objective of this study was to determine whether International Classification of Disease (ICD) codes for do-not-resuscitate (DNR) orders are valid proxies for the presence of a DNR recorded in the electronic medical record (EMR). METHODS: We studied 5,016 patients over the age of 65 who were admitted to a large, mid-Atlantic medical center with a primary diagnosis of heart failure. DNR orders were identified in billing records from ICD-9 and ICD-10 codes. DNR orders were also identified in the EMR by a manual search of physician notes. Sensitivity, specificity, positive predictive value and negative predictive value were calculated as well as measures of agreement and disagreement. In addition, estimates of associations with mortality and costs were calculated using the DNR documented in EMR and the DNR proxy identified in ICD codes. RESULTS: Relative to the gold standard of the EMR, DNR orders identified in ICD codes had an estimated sensitivity of 84.6%, specificity of 96.6%, positive predictive value of 90.5%, and negative predictive value of 94.3%. The estimated kappa statistic was 0.83, although McNemar's test suggested there was some systematic disagreement between the DNR from ICD codes and the EMR. CONCLUSIONS: ICD codes appear to provide a reasonable proxy for DNR orders among hospitalized older adults with heart failure. Further research is necessary to determine if billing codes can identify DNR orders in other populations.

The affordable care act and do-not-resuscitate orders: Differences by race and ethnicity.

BACKGROUND: The Affordable Care Act (ACA) created new payment rules that provided reimbursement for physicians to engage in advance care planning (ACP) conversations with patients. This reimbursement policy has the potential to increase ACP participation, including among racial and ethnic minority groups that have had lower ACP participation. OBJECTIVES: To examine whether the ACP payment rules were associated with an increase in use of do-not-resuscitate (DNR) orders, particularly among racial and ethnic minority groups, among patients diagnosed with heart failure (HF) in California. METHODS: The California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data Set was used to identify a cohort of elderly patients with a principal diagnosis of HF. This study included 432,520 hospital admissions of patients over the age of 65 with a primary diagnosis of HF between 2012 and 2018. DNR status was identified using International Classification of Diseases, Clinical Modification Ninth and Tenth Revision, codes. RESULTS: There was a small increase in the utilization of DNR orders overall after the ACA reimbursement policy, but the change was not significantly different for all racial and ethnic groups when compared to white non-Hispanic patients. CONCLUSIONS: ACP payment rules provided in the ACA were associated with increased utilization of DNR, but the effect was not significantly different for racial and ethnic minorities hospitalized with HF in CA. Additional efforts are needed to increase ACP participation among racial and ethnic minorities.

Gender diversity in United States neurosurgery training programs.

OBJECTIVE: Neurosurgery continues to be one of the medical specialties with the lowest representation of females in both the resident and faculty workforce. Currently, there are limited available data on the gender distribution of faculty and residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery training programs. This information is critical to accurately measure the results of any effort to improve both the recruitment and retention of women in neurosurgery. The objective of the current study was to define the current gender distribution of faculty and residents in ACGME-accredited neurosurgery training programs. METHODS: Data publicly available through institutional and supplemental websites for neurosurgical faculty and residents at ACGME-accredited programs were analyzed for the 2017-2018 academic year. Data collected for faculty included gender, age, year of residency graduation, academic rank, h-index, American Board of Neurological Surgery certification status, and leadership positions. Resident data included gender and postgraduate year of training. RESULTS: Among the 109 ACGME-accredited neurosurgical residency programs included in this study, there were 1350 residents in training, of whom 18.2% were female and 81.8% were male. There are 1320 faculty, of whom 8.7% were female and 91.3% were male. Fifty-eight programs (53.2%) had both female faculty and residents, 35 programs (32.1%) had female residents and no female faculty, 4 programs (3.7%) had female faculty and no female residents, and 6 programs (5.5%) lacked both female residents and faculty. Six programs (5.5%) had incomplete data. Female faculty were younger, had lower h-indices, and were less likely to be board certified and attain positions of higher academic rank and leadership. CONCLUSIONS: This study serves to provide a current snapshot of gender diversity in ACGME-accredited neurosurgery training programs. While there are still fewer female neurosurgeons achieving positions of higher academic rank and serving in leadership positions than male neurosurgeons, the authors' findings suggest that this is likely due to the small number of women in the neurosurgical field who are the farthest away from residency graduation and serves to highlight the significant progress that has been made toward achieving greater gender diversity in the neurosurgical workforce.

Design of a virtual longitudinal observational study in Parkinson's disease (AT-HOME PD).

OBJECTIVE: The expanding power and accessibility of personal technology provide an opportunity to reduce burdens and costs of traditional clinical site-centric therapeutic trials in Parkinson's disease and generate novel insights. The value of this approach has never been more evident than during the current COVID-19 pandemic. We sought to (1) establish and implement the infrastructure for longitudinal, virtual follow-up of clinical trial participants, (2) compare changes in smartphone-based assessments, online patient-reported outcomes, and remote expert assessments, and (3) explore novel digital markers of Parkinson's disease disability and progression. METHODS: Participants from two recently completed phase III clinical trials of inosine and isradipine enrolled in Assessing Tele-Health Outcomes in Multiyear Extensions of Parkinson's Disease trials (AT-HOME PD), a two-year virtual cohort study. After providing electronic informed consent, individuals complete annual video visits with a movement disorder specialist, smartphone-based assessments of motor function and socialization, and patient-reported outcomes online. RESULTS: From the two clinical trials, 226 individuals from 42 states in the United States and Canada enrolled. Of these, 181 (80%) have successfully downloaded the study's smartphone application and 161 (71%) have completed patient-reported outcomes on the online platform. INTERPRETATION: It is feasible to conduct a large-scale, international virtual observational study following the completion of participation in brick-and-mortar clinical trials in Parkinson's disease. This study, which brings research to participants, will compare established clinical endpoints with novel digital biomarkers and thereby inform the longitudinal follow-up of clinical trial participants and design of future clinical trials.

Do-not-resuscitate orders and readmission among elderly patients with heart failure in Pennsylvania: An observational study, 2011 - 2014.

BACKGROUND: Readmissions for patients with heart failure (HF) continues to be a target of value-based purchasing initiatives. Do-not-resuscitate (DNR) orders-one part of advance care planning (ACP)-have been shown to be related to other patient outcomes but has not been explored as a risk factor for HF readmission. OBJECTIVES: Examine the association between DNR and 30-day readmissions among elderly patients with HF admitted to hospitals in Pennsylvania. METHODS: Data included hospital discharges from 2011 to 2014 of patients 65+ years with a primary diagnosis of HF. Logistic regression was used to model the relationship between DNR and 30-day readmission. RESULTS: Among 107,806 patients, 20.9% were readmitted within 30 days. After controlling for covariates, patients with HF who had a DNR were less likely to be readmitted to the hospital (OR=0.85, 95% CI: 0.80-0.91, p<0.001). CONCLUSIONS: Documentation of a DNR may inform efforts to reduce readmissions among elderly patients with HF.

The Pancreas in Child Abuse.

The pancreas can be a critical indicator of inflicted injury in young children. Due to its retroperitoneal location and the amount of incursion of the abdomen required to cause injury, the pancreas is unlikely to be significantly injured in minor trauma incidents. Typical blunt force injury mechanisms for the pancreas include motor vehicle collisions, inflicted injury from blows or kicks, and bicycle handlebar injuries with deep incursion of the abdomen. The death of a toddler is described in which a pancreatic injury was a critical indicator of abusive injury rather than the claimed accidental fall or cardiopulmonary resuscitation-related trauma. Review of the medical literature regarding the epidemiology, etiology, and pathology of childhood pancreatic injuries is discussed. Pancreatic injury is a marker of severe blunt force trauma and should rouse a suspicion of nonaccidental trauma in young children. In the absence of a severe, high velocity or deep abdominal incursion traumatic mechanism, such as motor vehicle collision or bicycle handlebar injury, pancreatic laceration specifically is a marker of inflicted injury in children under the age of five. Acad Forensic Pathol. 2018 8(2): 219-238.

Nervus Intermedius Symptoms following Surgical or Radiation Therapy for Vestibular Schwannoma.

OBJECTIVES: This study compares the functional outcomes of nevus intermedius impairment following surgery, radiation, or observation for the treatment of vestibular schwannoma. STUDY DESIGN: Retrospective cohort study. SETTINGS: Tertiary care medical center. SUBJECTS AND METHODS: We retrospectively examined 141 charts of patients with a vestibular schwannoma seen in the Dartmouth-Hitchcock Acoustic Neuroma Clinic between 2012 and 2014. Seventy-one patients underwent intervention (including radiation) as their primary treatment, and 70 were treated with observation. As part of routine care, patients were interviewed at clinic visits and with a questionnaire assessing nervus intermedius impairment. RESULTS: At presentation, 25 patients (19%) reported nervus intermedius impairment. Most common disturbances were xerophthalmia (dry eyes, 13%) and dysgeusia (taste alteration, 7.6%). Postintervention, 35 patients (53%) had ≥1 symptoms of nervus intermedius dysfunction, which is increased in comparison with patients in the observation group (17 patients, 26.5%, P < .05). Twelve intervention patients had symptoms resolve postoperatively, making no long-term difference between the observation and intervention groups (P = .20). Motor function of the facial nerve postoperatively is correlated with nervus intermedius symptoms. Surgical approaches were compared with radiation therapy, and no significant difference in nervus intermedius outcomes was found. CONCLUSION: This study demonstrates the clinical importance of monitoring nervus intermedius symptoms, since a high percentage of all patients undergoing intervention will be symptomatic during management. Patients with motor dysfunction are at a higher risk of developing nervus intermedius sequelae and need close follow-up. Although impairment is common, many symptoms will improve over time with no long-term difference between intervention patients and those under observation.

Review of otorrhea microbiology: is there a pathogenic role of corynebacter?

OBJECTIVE: Identification of a causative pathogen in otologic infections assists in maximizing therapy efficacy particularly in refractory and chronic cases. Current standards for treatment of otologic infections focus on targeted species (spp.) that are assumed to be the most common pathogens. Corynebacterium spp. may play a pathogenic role but are not routinely speciated or included in antibiotic susceptibility analysis. Our objective is to investigate the prevalence and pathogenicity of nondiphtheroid Corynebacterium spp. in commonly encountered purulent and mucopurulent otologic infections. STUDY DESIGN: Retrospective case review. SETTING: Academic tertiary referral center. PATIENTS: Review of 140 microbiology cultures from adults and children presenting with purulent and mucopurulent otologic infections from 2010 to 2012. INTERVENTION(S): Clinical history, demographics, and microbiology cultures with speciation and antibiotic susceptibility analyses. MAIN OUTCOME MEASURE(S): Microbiologic speciation and census, species association with clinical characteristics, antibiotic susceptibility to oral and systemic agents, therapy frequency and agent selection. RESULTS: Corynebacterium spp. was the second most common bacteria isolated from patients with clinically significant otologic infections. Corynebacterium spp. were found in 24 (33.3%) unique patients with otologic infections and were the only pathogen isolated in six (8.33%) patients. Corynebacterium-positive infections were significantly associated with the use of hearing aids, a diagnosis of chronic granular myringitis, and less otalgia. Corynebacterium isolates were highly resistant to first-line fluoroquinolone therapy. The majority of patients with Corynebacterium-positive infections harbored at least one resistant strain, and patients with strains resistant to first-line topical therapy had a nonsignificant trend to an alteration in antibiotic therapy after antibiotic susceptibility data became available. CONCLUSION: Corynebacterium spp. may be underestimated in their potential to cause clinically significant otologic infections. Our results indicate a potential need for expanding surveillance for Corynebacterium spp.

Loss of SMARCB1/INI1 expression in poorly differentiated chordomas.

Chordomas are malignant neoplasms that typically arise in the axial spine and primarily affect adults. When chordomas arise in pediatric patients they are more likely to display unusual histological features and aggressive behavior. We noted the absence of SMARCB1/INI1 expression by immunohistochemistry in an index case of poorly differentiated chordoma of the sacrum, leading us to further examine SMARCB1/INI1 expression as well as that of brachyury, a highly specific marker of notochordal differentiation, in 3 additional poorly differentiated chordomas of the clivus, 10 typical chordomas, and 8 atypical teratoid/rhabdoid tumors (AT/RTs). All 4 poorly differentiated chordomas and all AT/RTs lacked nuclear expression of SMARCB1/INI1, while the 10 typical chordomas maintained strong nuclear SMARCB1/INI1 immunoreactivity. All 10 typical and 4 poorly differentiated chordomas expressed brachyury; all 8 AT/RTs were brachyury immunonegative. Cytogenetic evaluation utilizing FISH probes near the SMARCB1/INI1 locus on chromosome 22q was also performed in all of the poorly differentiated chordomas in this series. Three of the four poorly differentiated chordomas had evidence for deletion of this region by FISH. Analysis of the SMARCB1/INI1 gene sequence was performed using formalin-fixed paraffin-embedded tissue in all cases and no point mutations were observed. In summary, all poorly differentiated chordomas in this series showed the absence of SMARCB1/INI1 expression, and were reliably distinguished from AT/RTs, clinically by their characteristic primary sites of origin and pathologically by strong nuclear brachyury expression. Our findings reveal a likely role for SMARCB1/INI1 in a subset of chordomas with aggressive features.

Desmoplastic fibroma of bone with extensive cartilaginous metaplasia.

Desmoplastic fibroma of bone is a rare tumor demonstrating the same histologic and biologic features of its soft tissue counterpart, aggressive fibromatosis. We report the second case of desmoplastic fibroma of bone with extensive chondroid metaplasia. The tumor arose in the left ischium of a 51-year-old male, with extension into adjacent musculature as a pseudoencapsulated mass. The infiltrating growth and quality of the fibrous component are characteristic of desmoplastic fibroma, and in addition, abrupt transitions into bland hyalin cartilage were frequent. Discriminating features of this lesion from other bone tumors capable of biphasic expression of fibrous and chondroid elements are discussed.