Utility of Routine Surveillance Head Computed Tomography After Receiving Therapeutic Anticoagulation in Patients with Acute Traumatic Intracranial Hemorrhage.

INTRODUCTION: Patients with traumatic intracranial hemorrhage (tICH) are at increased risk of venous thromboembolism and may require anticoagulation. We evaluated the utility of surveillance computed tomography (CT) in patients with tICH who required therapeutic anticoagulation. METHODS: This single institution, retrospective study included adult patients with tICH who required anticoagulation within 4 weeks and had a surveillance head CT within 24 hours of reaching therapeutic anticoagulation levels. The primary outcome was hematoma expansion (HE) detected by the surveillance CT. Secondary outcomes included 1) changes in management in patients with HE on the surveillance head CT, 2) HE in the absence of clinical changes, and 3) mortality due to HE. We also compared mortality between patients who did and did not have a surveillance CT. RESULTS: Of 175 patients, 5 (2.9%) were found to have HE. Most (n = 4, 80%) had changes in management including anticoagulation discontinuation (n = 4), reversal (n = 1), and operative management (n = 1). Two patients developed symptoms or exam changes prior to the head CT. Of the 3 patients (1.7%) without preceding exam changes, each had only very minor HE and did not require operative management. No patient experienced mortality directly attributed to HE. There was no difference in mortality between patients who did and those who did not have a surveillance scan. CONCLUSIONS: Our findings suggest that most patients with tICH who are started on anticoagulation could be followed clinically, and providers may reserve CT imaging for patients with changes in exam/symptoms or those who have a poor clinical examination to follow.

Incidence and Risk Model of Post-Traumatic Hydrocephalus in Patients with Traumatic Brain Injury.

OBJECTIVE: Post-traumatic hydrocephalus (PTH) is a complication following traumatic brain injury (TBI). Early diagnosis and treatment are essential to improving outcomes. We report the incidence and risk factors of PTH in a large TBI population while considering death as a competing risk. METHODS: We conducted a retrospective cohort study on consecutive TBI patients with radiographic intracranial abnormalities admitted to our academic medical center from 2009 to 2015. We assessed patient demographics, perioperative data, and in-hospital data as risk factors for PTH using survival analysis with death as a competing risk. RESULTS: Among 7,473 patients, the overall incidence of PTH requiring shunt surgery was 0.94%. The adjusted cumulative incidence was 0.99%. The all-cause cumulative hazard for death was 32.6%, which was considered a competing risk during analysis. Craniectomy (HR 11.53, P < 0.001, 95% CI 5.57-223.85), venous sinus injury (HR 4.13, P = 0.01, 95% CI 1.53-11.16), and age ≤5 (P < 0.001) were significant risk factors for PTH. Glasgow Coma Score (GCS) > 13 was protective against shunt placement (HR 0.50, P = 0.04, 95% CI 0.26-0.97). Shunt surgery occurred after hospital discharge in 60% of patients. CONCLUSIONS: We describe the incidence and risk factors for PTH in a large traumatic brain injury (TBI) population. Most cases of PTH were diagnosed after hospital discharge, suggesting that close follow-up and multidisciplinary diagnostic vigilance for PTH are needed to prevent morbidity and disability.

Intraoperative neuromonitoring potentials and evidence of preserved neuronal circuitry below the anatomical and functional level in patients with complex spinal dysraphism undergoing detethering reoperations.

OBJECTIVE: Spina bifida represents one of the most common birth defects, occurring in approximately 1-2 children per 1000 live births worldwide. The functional level of patients with spina bifida is highly variable and believed to be correlated with the anatomical level of the lesion. The variable clinical picture is well established, but the correlation with anatomical level and intraoperative neuromonitoring (IONM) data has not been investigated. Furthermore, the potential for preserving function beyond the apparent clinical level has also not been investigated. The objective of this research was to determine the presence and level of intraoperative transcranial motor evoked potential (tcMEP) and triggered electromyography (tEMG) responses, and the association of these responses with preoperative clinical function and radiographic data in pediatric cases of complex tethered cord release reoperations. METHODS: A single-center retrospective review of pediatric patients with complex spinal dysraphism undergoing detethering reoperations was conducted. Preoperative demographic and clinical data, including the radiographic and clinical level of dysraphism, were collected. IONM, including tcMEPs and tEMG responses, were obtained and compared with preoperative clinical data. Descriptive analysis was performed, by patient for demographics and by case for surgeries performed. RESULTS: In 100% of 21 cases of complex detethering reoperations, representing 20 patients, intraoperative tcMEPs could be generated at (4.8%) or below (95.2%) the level of clinical function. Compared with the preoperative clinical examination, 5 cases (23.8%) demonstrated tcMEP responses that were 1 level below the clinical function level, 11 cases (52.4%) were 2 levels below, and 4 cases (19.0%) were 3 levels below. Overall, 18 of 21 cases showed tEMG responses at or below the level of clinical function; of these, 7 cases (33%) were 1 level below and 3 (14%) were ≥ 2 levels below the clinical function level. CONCLUSIONS: The presence of positive stimulation potentials below the level of clinical function in patients with complex spinal dysraphism undergoing detethering reoperations indicates a degree of preserved neuronal connectivity. These findings suggest novel future treatment approaches for these patients, including using devices targeted to stimulation of these neurological pathways.

Yoga as a non-pharmacologic therapy to reduce dinutuximab-induced pain in patients with neuroblastoma.

BACKGROUND: Anti-GD2 antibodies are key components of treatment for high-risk neuroblastoma; however, they cause neuropathic pain. Yoga therapy may help reduce pain and distress associated with anti-GD2 therapy. PROCEDURE: Children 3 years of age or older with neuroblastoma participated in individualized yoga therapy while receiving the anti-GD2 antibody dinutuximab (DIN). Yoga therapy was deemed feasible if patients participated during 60% or more of DIN admissions. Patients and caregivers assessed pain/distress before and after yoga therapy with a distress thermometer (DT) and Wong-Baker FACES pain rating scale and completed questionnaires regarding satisfaction with yoga therapy. Therapy was deemed efficacious if there was a ≥1 point pain score change and reduction in distress after yoga. RESULTS: Eighteen patients were enrolled; 52 encounters (admissions for DIN) were evaluable. Ten of 18 were female, three of 18 were Hispanic, and 10/18 were White. Median age at enrollment was 5.5 years (range: 3-11). Yoga therapy was feasible in 39/52 (75%) encounters. Significant reductions in caregiver-reported pain and distress and reductions in patient-reported pain and distress after yoga therapy were reported. Twelve of 18 caregivers completed questionnaires: seven agreed/strongly agreed that yoga was valuable, and nine agreed/strongly agreed to continued participation in yoga. Thirty-four of 36 clinicians reported that they would recommend yoga therapy for other patients receiving DIN. CONCLUSIONS: Yoga therapy was feasible during DIN therapy and may be effective in reducing DIN-associated pain and distress. Future studies are needed to evaluate changes in opioid usage with the addition of yoga therapy during anti-GD2 antibody therapy.

Transmission of Spinach Downy Mildew via Seed and Infested Leaf Debris.

Spinach downy mildew, caused by the obligate oomycete pathogen Peronospora effusa, is a worldwide constraint on spinach production. The role of airborne sporangia in the disease cycle of P. effusa is well established, but the role of the sexual oospores in the epidemiology of P. effusa is less clear and has been a major challenge to examine experimentally. To evaluate seed transmission of spinach downy mildew via oospores in this study, isolated glass chambers were employed in two independent experiments to grow out oospore-infested spinach seed and noninfested seeds mixed with oospore-infested crop debris. Downy mildew diseased spinach plants were observed 37 and 34 days after planting in the two isolator experiments, respectively, in the chambers that contained one of two oospore-infested seed lots or seeds coated with oospore-infested leaves. Spinach plants in isolated glass chambers initiated from seeds without oospores did not show downy mildew symptoms. Similar findings were obtained using the same seed lot samples in a third experiment conducted in a growth chamber. In direct grow out tests to examine oospore infection on seedlings performed in a containment greenhouse with oospore-infested seed of two different cultivars, characteristic Peronospora sporangiophores were observed growing from a seedling of each cultivar. The frequency of seedlings developing symptoms from 82 of these oospore-infested seed indicated that approximately 2.4% of seedlings from infested seed developed symptoms, and 0.55% of seedlings from total seeds assayed developed symptoms. The results provide evidence that oospores can serve as a source of inoculum for downy mildew and provide further evidence of direct seed transmission of the downy mildew pathogen to seedlings in spinach via seedborne oospores.

Efficacy and safety of cosibelimab, an anti-PD-L1 antibody, in metastatic cutaneous squamous cell carcinoma.

BACKGROUND: Programmed cell death receptor-1 (PD-1)-blocking antibodies are approved to treat metastatic or locally advanced cutaneous squamous cell carcinoma (CSCC) cases ineligible for curative surgery or radiation. Notwithstanding, some patients experience inadequate responses or severe immune-related adverse events (AEs), indicating the need for improved therapies. Cosibelimab is a high-affinity programmed cell death-ligand 1 (PD-L1)-blocking antibody that activates innate and adaptive immunity by blocking PD-L1 interaction with PD-1 and B7-1 receptors. It is an unmodified immunoglobulin G1 subtype with a functional Fc domain capable of inducing antibody-dependent cellular cytotoxicity and complement-dependent cytotoxicity. Here, we present results of the pivotal study of patients with metastatic CSCC from an open-label, multicenter, multiregional, multicohort, phase 1 trial of cosibelimab. METHODS: In this trial, participants with metastatic CSCC received cosibelimab 800 mg intravenously every 2 weeks. Primary endpoint was objective response rate (ORR) by independent central review using Response Evaluation Criteria in Solid Tumors, V.1.1. Secondary endpoints included duration of response (DOR) and safety. RESULTS: Objective response was observed in 37 of 78 participants (47.4% (95% CI: 36.0% to 59.1%)), with median follow-up of 15.4 months (range: 0.4 to 40.5) as of data cut-off. Median DOR was not reached (range: 1.4+ to 34.1+ months), with response ongoing in 73.0% of participants. Common treatment-emergent AEs (≥15%) were fatigue (26.9%), rash (16.7%), and anemia (15.4%). Eighteen participants (23.1%) experienced immune-related AEs (grade 3: n=2 (2.6%); no grade 4/5). No treatment-related deaths were reported. CONCLUSIONS: Cosibelimab demonstrated clinically meaningful ORR and DOR and was associated with a manageable safety profile. TRIAL REGISTRATION NUMBER: NCT03212404.

Deep spatial-omics analysis of Head & Neck carcinomas provides alternative therapeutic targets and rationale for treatment failure.

Immune checkpoint inhibitor (ICI) therapy has had limited success (<30%) in treating metastatic recurrent Head and Neck Oropharyngeal Squamous Cell Carcinomas (OPSCCs). We postulate that spatial determinants in the tumor play a critical role in cancer therapy outcomes. Here, we describe the case of a male patient diagnosed with p16+ OPSCC and extensive lung metastatic disease who failed Nivolumab and Pembrolizumab/Lenvatinib therapies. Using advanced integrative spatial proteogenomic analysis on the patient's recurrent OPSCC tumors we demonstrate that: (i) unbiased tissue clustering based on spatial transcriptomics (ST) successfully detected tumor cells and enabled the investigation of phenotypic traits such as proliferation or drug-resistance genes in the tumor's leading-edge and core; (ii) spatial proteomic imagining used in conjunction with ST (SpiCi, Spatial Proteomics inferred Cell identification) can resolve the profiling of tumor infiltrating immune cells, (iii) ST data allows for the discovery and ranking of clinically relevant alternative medicines based on their interaction with their matching ligand-receptor. Importantly, when the spatial profiles of ICI pre- and post-failure OPSCC tumors were compared, they exhibited highly similar PD-1/PD-L1low and VEGFAhigh expression, suggesting that these new tumors were not the product of ICI resistance but rather of Lenvatinib dose reduction due to complications. Our work establishes a path for incorporating spatial-omics in clinical settings to facilitate treatment personalization.

Chronic frontal neurobehavioural symptoms in combat-deployed military personnel with and without a history of blast-related mild traumatic brain injury.

OBJECTIVE: This study evaluated frontal behavioural symptoms, via the FrSBe self-report, in military personnel with and without a history of blast-related mild traumatic brain injury (mild TBI). METHODS: Prospective observational cohort study of combat-deployed service members leveraging 1-year and 5-year demographic and follow up clinical outcome data. RESULTS: The blast mild TBI group (n = 164) showed greater frontal behavioural symptoms, including clinically elevated apathy, disinhibition, and executive dysfunction, during a 5-year follow-up, compared to a group of combat-deployed controls (n = 107) without mild TBI history or history of blast exposure. We also explored changes inbehaviourall symptoms over a 4-year span, which showed clinically significant increases in disinhibition in the blast mild TBI group, whereas the control group did not show significant increases in symptoms over time. CONCLUSION: Our findings add to the growing evidence that a proportion of individuals who sustain mild TBI experience persistent behavioural symptoms. We also offer a demonstration of a novel use of the FrSBe as a tool for longitudinal symptom monitoring in a military mild TBI population.

Understanding the Genotypic and Phenotypic Structure and Impact of Climate on Phytophthora nicotianae Outbreaks on Potato and Tomato in the Eastern United States.

Samples from potato fields with lesions with late blight-like symptoms were collected from eastern North Carolina in 2017 and the causal agent was identified as Phytophthora nicotianae. We have identified P. nicotianae in potato and tomato samples from North Carolina, Virginia, Maryland, Pennsylvania, and New York. Ninety-two field samples were collected from 46 fields and characterized for mefenoxam sensitivity, mating type, and simple sequence repeat genotype using microsatellites. Thirty-two percent of the isolates were the A1 mating type, while 53% were the A2 mating type. In six cases, both A1 and A2 mating types were detected in the same field in the same year. All isolates tested were sensitive to mefenoxam. Two genetic groups were discerned based on STRUCTURE analysis: one included samples from North Carolina and Maryland, and one included samples from all five states. The data suggest two different sources of inoculum from the field sites sampled. Multiple haplotypes within a field and the detection of both mating types in close proximity suggests that P. nicotianae may be reproducing sexually in North Carolina. There was a decrease in the average number of days with weather suitable for late blight, from 2012 to 2016 and 2017 to 2021 in all of the North Carolina counties where P. nicotianae was reported. P. nicotianae is more thermotolerant than P. infestans and grows at higher temperatures (25 to 35°C) than P. infestans (18 to 22°C). Late blight outbreaks have decreased in recent years and first reports of disease are later, suggesting that the thermotolerant P. nicotianae may cause more disease as temperatures rise due to climate change.

Breaking Healthcare Barriers for Transgender Individuals With Rare Tumor Presentation.

Transgender persons can experience healthcare barriers and potentially suffer from preventable health disparities. Some challenges these individuals may face include the lack of provider education, social stigma, socioeconomic barriers to care, and insurance instability. Combating this problem requires systemic changes. Unfortunately, there are limited data on providers' perspective on taking care of transgender persons, and healthcare delivery systems are often unequipped to adequately manage these patients. This case presentation exemplifies many of these challenges. A 47-year-old transgender female with a history of testicular cancer, presented with bleeding from a lump on her neck. A computed tomography (CT) scan of the neck revealed a large mass suspicious of malignancy. Pathology identified metastatic colorectal adenocarcinoma. Esophagogastroduodenoscopy, colonoscopy, positron emission tomography scan, CT abdomen/pelvis, and serum tumor marker showed no evidence of a primary gastrointestinal malignancy. This presentation likely represents a late relapse of a residual, metastatic germ cell tumor with malignant somatic transformation. This case was greatly impacted by social determinants of health. The patient did not identify with her male anatomy, which delayed the detection of the initial testicular malignancy. In the post-operative period, the patient did not attend follow-up appointments to avoid discussing her male genitalia. When tumor relapse did occur, the patient experienced financial, insurance, and transportation instability; this delayed medical care and allowed the mass to grow to an extraordinary size.

Efficacy of Organic Fungicides for Downy Mildew in Field-Grown Sweet Basil.

Downy mildew is a common, widespread disease affecting basil leaves. No tolerance for disease symptoms, especially on leaves for fresh consumption, necessitates management. Six replicated experiments were conducted between 2010 and 2016 with field-grown basil of a susceptible cultivar exposed to naturally occurring, wind-dispersed sporangiospores of Peronospora belbahrii to evaluate fungicides approved for use on organically produced crops and products in development. Products tested currently registered for use on basil in the U.S. and labeled for downy mildew were Actinovate (Streptomyces lydicus), Companion (Bacillus subtilis), Cueva (copper octanoate), Double Nickel (Bacillus amyloliquefaciens), Forticept EP #1 (thyme oil), Milagrum Plus (Bacillus subtilis), Organocide (sesame oil), Oso (polyoxin D zinc salt), OxiDate (hydrogen dioxide), Procidic (citric acid), Regalia (Reynoutria sachalinensis extract), Stargus (Bacillus amyloliquefaciens), and Trilogy (neem oil). Most are biopesticides. A conventional fungicide, Revus (mandipropamid), was included in most experiments as a positive control. Applications were made weekly to foliage with a backpack sprayer starting before symptoms were seen, except in 2013 when disease onset was early and 2015 when applications were made twice weekly. Organic treatments tested in 2013 started with a soil drench application around the base of plants two days after transplantation. Fungicide efficacy was assessed based on incidence of symptomatic leaves rather than disease severity because there is no tolerance for disease on fresh-market herbs. None were effective based on weekly severity assessments or AUDPC values, confirming results from other researchers that downy mildew cannot be effectively managed with organic fungicides applied to susceptible basil cultivars.

Phytophthora capsici, 100 Years Later: Research Mile Markers from 1922 to 2022.

In 1922, Phytophthora capsici was described by Leon Hatching Leonian as a new pathogen infecting pepper (Capsicum annuum), with disease symptoms of root rot, stem and fruit blight, seed rot, and plant wilting and death. Extensive research has been conducted on P. capsici over the last 100 years. This review succinctly describes the salient mile markers of research on P. capsici with current perspectives on the pathogen's distribution, economic importance, epidemiology, genetics and genomics, fungicide resistance, host susceptibility, pathogenicity mechanisms, and management.

Providing culturally appropriate residential dementia care for older adults with an Indian heritage: Perspectives from Sydney-based stakeholders.

BACKGROUND AND OBJECTIVES: Global migration and an increased life expectancy led to a growing number of people with dementia from Culturally and Linguistically Diverse (CaLD) backgrounds living in long-term residential care settings. These minority groups' wellbeing may be negatively impacted due to poor culturally appropriate care that fails to honour valued cultural traditions. This study considered culturally appropriate dementia care for older adults with an Indian heritage living in Sydney-based residential aged care facilities. RESEARCH DESIGN AND METHODS: The Nominal Group Technique was employed to collect data from three groups of stakeholders of Indian heritage over a period of 6 months: care staff (n = 8), family of residential care recipients (n = 8), and community-dwelling older adults (n = 7). RESULTS: Perspectives highlighted six concepts for consideration: (1) embracing a person-centred approach to promote culturally appropriate dementia care; (2) training staff in culturally appropriate forms of respect; (3) the impact of staff ratios on care; (4) the importance of familiarity to meaningful engagement; (5) the importance of food; and (6) the necessity of engaging family and the wider Indian community in residential care activities. CONCLUSIONS: Culturally appropriate dementia care for older adults with an Indian heritage is an area in need of further development. To ensure that residents with an Indian heritage are respected as an ethnic minority, it remains crucial that research is generated to inform policy development on each CaLD group as a separate entity.

Mixed Study Systematic Review and Meta-analysis of Sexuality and Sexual Rehabilitation in LGBTQI+ Adults Living With Chronic Disease.

OBJECTIVE: To systematically review how sexuality is experienced by lesbian, gay, bisexual, transgender, queer or questioning, intersex plus (other gender identifies and sexual orientations) (LGBTQI+) persons living with chronic disease. DATA SOURCES: PsycINFO, Embase, MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health, and Web of Science were searched from date of inception to November 2021 for English language publications. Reference lists of relevant publications were also searched. STUDY SELECTION: Eligible studies reported on sexuality among LGBTQI+ persons living with chronic disease. The search yielded 12,626 records; 665 full texts were assessed for eligibility and 63 documents included (59 unique studies). Study quality was rated using the Mixed Methods Appraisal Tool. DATA EXTRACTION: Characteristics of included studies were recorded independently by 2 authors. Differences were resolved through discussion or with a third author. DATA SYNTHESIS: A sequential, exploratory mixed-studies approach was used for synthesis. Pooled analysis indicated that among gay and bisexual men living with prostate cancer, 68.3% experienced erectile dysfunction and 62.9% had insufficient quality of erection to engage in anal sex. Among gay and bisexual men living with HIV or AIDS, 29.3% experienced loss of libido and 25.3% experienced erectile dysfunction. Although sexual dysfunction was common, LGBTQI+ persons had difficulty accessing appropriate sexual counseling and identified negative attitudes and heteronormative assumptions by health care providers as significant barriers to sexual health. Interventions to address sexuality focused entirely on reduction of risky sexual behavior among men living with HIV or AIDS. Women, transgender persons, and intersex persons were largely excluded from the research studies. CONCLUSIONS: Current understandings of the effect of chronic disease on LGBTQI+ sexuality are limited and mostly focus on the male sexual response. LGBTQI+ persons who experience difficulty with sexuality struggle to identify appropriate services, and there is an absence of evidence-based interventions to promote sexual health and well-being in this population.

Traumatic Pseudoaneurysm of the Occipital Artery Treated with Open Surgical Ligation: 2-Dimensional Operative Video.

Scalp pseudoaneurysms occur most commonly because of trauma and are often in the superficial temporal artery due to the lack of soft tissue coverage between skin and bone, making it more vulnerable anatomically.1,2 Pseudoaneurysms of the occipital artery (OA) also occur but are extremely rare.2-4 An 80-year-old man presented with scalp bleeding and a small left-sided posterior scalp laceration after a fall and head strike 10 days prior. He was admitted and during his 2-week hospital stay, the occipital laceration continued to rebleed (Video 1). He developed a 2-cm pulsatile ulcerative mass with central necrosis on the left nuchal ridge. Computed tomography angiography revealed an ovoid left occipital lesion measuring 1.3 × 2.5 × 2.3 cm with delayed contrast filling and partial thrombosis. The base of the lesion had dense contrast filling continuous with the OA, diagnostic of OA pseudoaneurysm. OA pseudoaneurysm may be treated endovascularly or surgically. While surgical resection is the most common treatment, minimally invasive techniques have been successfully done through direct injection of N-butyl cyanoacrylate or endovascular embolization. The clinical presentation of this case was unique because this patient had an ulcerated lesion with central necrosis overlying the pseudoaneurysm. Endovascular management alone would not address the open lesion, which is at high risk for infection. The risk of infection would increase after embolization of the occipital artery, causing further necrosis of the tissue.

Reactivation of Disseminated Histoplasmosis With Central Nervous System Involvement Following a Primary Gastrointestinal Histoplasmosis Infection: A Case Report.

A 78-year-old white male with chronic pancytopenia presented with acute transient aphasia and dysarthria. He had a National Institutes of Health Stroke Scale (NIHSS) of zero. Physical examination revealed slight aphasia with mild dysarthria. Brain magnetic resonance imaging (MRI) revealed nine ring-enhancing lesions in the left precentral gyrus with significant vasogenic edema. Lung computed tomography (CT) showed no evidence of pulmonary nodules. The serology of blood and urine for infectious organisms was negative. Four weeks later, the patient was re-admitted with worsening dysarthria and right upper extremity weakness. Repeat head MRI showed a slight increase in the size of the multiple supratentorial ring-enhancing lesions. The magnetic resonance spectroscopy (MRS) findings of the evaluated lesion suggested a fungal etiology. Empiric amphotericin B treatment was initiated, which mitigated central nervous system (CNS) ring-enhancing lesions and resolved the patient's neurological deficits. Early empiric medical treatment of CNS histoplasmosis should be considered in the setting of multiple CNS ring-enhancing lesions and a positive history of histoplasmosis infection, despite negative serological studies.

Primary Intracranial Brainstem Malignant Melanoma: A Technical Case Report.

BACKGROUND AND IMPORTANCE: Primary intracranial malignant melanomas (PIMMs) are quite rare, comprising 1% of melanomas and 0.07% of intracranial tumors. PIMMs have been reported in a variety of intracranial locations, but there has only been 1 reported instance of PIMM occurring in the brainstem. In this study, we describe the second reported case of primary pontine malignant melanoma and its treatment. CLINICAL PRESENTATION: A 40-year-old man presented with right hemiparesis, diplopia, and dysarthria. MRI demonstrated a hemorrhagic, expansile, and heterogeneously enhancing lesion in the left pons with edema extending to the left thalamus and posterior limb of the internal capsule. Surgical resection was performed through a transpetrosal approach. Pathology resulted as malignant melanoma immunopositive for BRAF V600E mutation. Complete oncological workup revealed no other lesions; thus, he was diagnosed with PIMM of the brainstem. CONCLUSION: We report a rare case of primary pontine malignant melanoma in which microsurgical resection resulted in dramatic clinical improvement despite the challenging location. This is only the second reported case of brainstem PIMM. More patients with longer-term follow-up will be necessary to determine the best treatment approach.

De novo epilepsy after microsurgical resection of brain arteriovenous malformations.

OBJECTIVE: Seizures are the second most common presenting symptom of brain arteriovenous malformations (bAVMs) after hemorrhage. Risk factors for preoperative seizures and subsequent seizure control outcomes have been well studied. There is a paucity of literature on postoperative, de novo seizures in initially seizure-naïve patients who undergo resection. Whereas this entity has been documented after craniotomy for a wide variety of neurosurgically treated pathologies including tumors, trauma, and aneurysms, de novo seizures after bAVM resection are poorly studied. Given the debilitating nature of epilepsy, the purpose of this study was to elucidate the incidence and risk factors associated with de novo epilepsy after bAVM resection. METHODS: A retrospective review of patients who underwent resection of a bAVM over a 15-year period was performed. Patients who did not present with seizure were included, and the primary outcome was de novo epilepsy (i.e., a seizure disorder that only manifested after surgery). Demographic, clinical, and radiographic characteristics were compared between patients with and without postoperative epilepsy. Subgroup analysis was conducted on the ruptured bAVMs. RESULTS: From a cohort of 198 patients who underwent resection of a bAVM during the study period, 111 supratentorial ruptured and unruptured bAVMs that did not present with seizure were included. Twenty-one patients (19%) developed de novo epilepsy. One-year cumulative rates of developing de novo epilepsy were 9% for the overall cohort and 8.5% for the cohort with ruptured bAVMs. There were no significant differences between the epilepsy and no-epilepsy groups overall; however, the de novo epilepsy group was younger in the cohort with ruptured bAVMs (28.7 ± 11.7 vs 35.1 ± 19.9 years; p = 0.04). The mean time between resection and first seizure was 26.0 ± 40.4 months, with the longest time being 14 years. Subgroup analysis of the ruptured and endovascular embolization cohorts did not reveal any significant differences. Of the patients who developed poorly controlled epilepsy (defined as Engel class III-IV), all had a history of hemorrhage and half had bAVMs located in the temporal lobe. CONCLUSIONS: De novo epilepsy after bAVM resection occurs at an annual cumulative risk of 9%, with potentially long-term onset. Younger age may be a risk factor in patients who present with rupture. The development of poorly controlled epilepsy may be associated with temporal lobe location and a delay between hemorrhage and resection.

Frailty Predicts Postoperative Functional Outcomes After Microsurgical Resection of Ruptured Brain Arteriovenous Malformations in Older Patients.

OBJECTIVE: To determine the effectiveness of the modified Frailty Index-5 (mFI-5) in predicting postoperative functional outcome after microsurgical resection of ruptured brain arteriovenous malformations (bAVMs). METHODS: A retrospective review was performed of patients undergoing microsurgical resection of acutely ruptured bAVMs. Demographics, bAVM characteristics, mFI-5, Ruptured Arteriovenous Malformation Grading Scale (RAGS) score, and Spetzler-Martin (S-M) grade were recorded. Predictive ability of mFI-5 for postoperative functional outcome measured by modified Rankin Scale (mRS) was assessed with univariate and multivariate logistic and linear regression. RAGS score and S-M grade alone were compared with adding mFI-5 to either RAGS score or S-M grade using area under the curve (AUC) analysis. RESULTS: In total, 109 patients were included. For every 1-point increase in mFI-5, there was a lower likelihood of good functional outcome (mRS score ≤2; odds ratio [OR], 0.33; confidence interval [CI], 0.15-0.60; P = 0.011). Healthy patients (mFI-5 = 0) were more likely to have good postoperative outcomes versus frail patients (mFI-5 ≥1) (OR, 3.32; CI, 1.24-8.97; P = 0.017). In multivariate analysis controlling for RAGS score, for every 1-point mFI-5 increase, there was a decreased likelihood of postoperative good functional outcome (OR, 0.32; CI, 0.14-0.63; P = 0.0026) and mFI-5 did not significantly predict secondary outcomes. S-M grade with mFI-5 showed better discrimination for postoperative good functional outcome (AUC 0.616), compared with S-M grade alone (AUC 0.544). RAGS score with mFI-5 showed the best discrimination for postoperative good functional outcome (AUC 0.798), compared with RAGS score alone (AUC 0.721). CONCLUSIONS: Measuring frailty with mFI-5 additive to established bAVM grading systems may improve assessment of individual patient likelihood of postoperative good functional outcome after hemorrhagic bAVM resection.

First Report of Bacterial Blight on arugula (Eruca vesicaria subsp. sativa) caused by Pseudomonas cannabina pv. alisalensis in New York.

Bacterial blight of arugula (Eruca vesicaria subsp. sativa cv. Standard) was observed in a commercial crop being grown in a high tunnel under overhead irrigation in Argyle, NY in January 2021. Approximately 80-100% of the plants were affected. Symptoms started as small, angular, water-soaked lesions visible on both sides of the leaves, then expanded, coalesced and later dried and turned tan. Fluorescent pseudomonads from five different plants were isolated on King's medium B agar amended with boric acid, chloramphenicol, and cycloheximide (Schaad et al. 2001) from surface disinfested symptomatic leaf tissues macerated in phosphate buffer (10mM, pH 7.0). Five representative isolates from each of the five plants produced levan and were negative for arginine dihydrolase and oxidase. They did not rot potatoes but were able to induce a hypersensitive reaction on tobacco (Nicotiana tabacum L. cv Glurk) within 24 h, thus demonstrating that the isolates belonged to LOPAT group 1 (Lelliott et al. 1966). DNA fragment banding patterns of these isolates generated by repetitive extragenic palindromic sequence PCR (repPCR) with BOXA1R primers were compared to the pathotype strains of Pseudomonas cannabina pv. alisalensis and Pseudomonas syringae pv. maculicola, known fluorescent pathogens of the Brassicaceae. The repPCR banding pattern of all isolates matched the pattern of Pseudomonas cannabina pv. alisalensis. Bacterial inoculum for pathogenicity experiments was prepared from 48 h KBBC agar cultures suspended in phosphate buffer (10mM, pH 7.0) and adjusted to 0.6 optical density at 600nm yielding approximately 108 CFU/ml. Five-week-old arugula plants were sprayed until run-off with one of the three isolates from arugula, a negative control (sterile buffer), or a positive control (P. cannabina pv. alisalensis) that is pathogenic to crucifers and also reported to cause disease on arugula in California (Bull et al. 2004). Experiments consisted of three replications of each treatment and two independent experiments were conducted. Small water-soaked spots resembling the original symptoms developed on all plants inoculated with the three representative isolates and P. cannabina pv. alisalensis. Moreover, reisolates from the symptomatic tissues were fluorescent on KBBC and had identical repPCR banding pattern as inoculated strains, demonstrating Koch's postulates. To our knowledge, this is the first report of bacterial blight on arugula caused by Pseudomonas cannabina pv. alisalensis in the Northeastern US. It was previously reported in California, Nevada, and Minnesota (Bull and du Toit 2009; Bull et al. 2004). This report may have significance for all brassica leafy green growers in the Northeast as P. cannabina pv. alisalensis has a broad host range including members of the Brassicaceae and oats which are commonly used as cover crops in mixed vegetable production.