Older Adults with Vestibular Disorders and Hip Fractures Have High Rates of Meclizine Use.

OBJECTIVES: To examine the risk factors for hip fracture in patients with vestibular disorders and the association between antihistamine use and hip fracture in patients with vestibular disorders. STUDY DESIGN: Retrospective case series with chart review. SETTING: Tertiary academic medical center. METHODS: A retrospective review of adult patients with hip fracture based on International Classification of Diseases, Tenth Revision (ICD-10) code S72 from January 2013 to December 2019 who had previously been diagnosed with a vestibular disorder based on ICD-10 codes H81-83, A88.1, and R42. RESULTS: A total of 201 patients were identified meeting the inclusion criteria. The average age at the time of hip fracture was 78.8 years and the majority were female (64.7%). Most patients were diagnosed with nonspecific dizziness (60.2%) or vertigo (23.9%). Those with a peripheral vestibular disorder included benign paroxysmal positional vertigo (BPPV) in 13.4% and Ménière's disease in 2.5%. Overall, meclizine was prescribed to 38.3% of patients, including 29.9% of patients before hip fracture. Meclizine was prescribed to 66.7% of patients with BPPV. Patients were seen for vestibular symptoms 0.67 ± 2.51 years before hip fracture, and 98 patients (48.8%) presented with vestibular concerns within 1 year prior. CONCLUSION: Patients with vestibular disorders who sustain a ground level fall resulting in hip fracture are a vulnerable population of predominantly older adults with multiple comorbidities. Patients were frequently diagnosed with dizziness or vertigo rather than more specific causes being identified. Multifactorial interventions to prevent hip fractures in older adults have been recommended; however, this study suggests that meclizine use was common among patients diagnosed with dizziness, vertigo, or BPPV before hip fracture.

Clinical Diagnosis and Management of Mucosal Leishmaniasis in the Context of a Global Pandemic: A Case Report.

Mucosal leishmaniasis (ML) is a rare metastatic complication of Leishmania infection. It has a high potential for destructive and disfiguring complications, namely destruction of nasal architecture and airway compromise. ML is difficult to treat for a variety of reasons, including variable antimicrobial resistance rates between species, as well as between endemic areas geographically. There are several treatment options available, which are discussed here. In the majority of cases, a nuanced approach to treatment is required based on speciation and geography. Importantly, the treatment of ML requires a multi-disciplinary approach. We present a patient with a history of cutaneous leishmaniasis who presented with signs and symptoms concerning ML, but due to the COVID-19 global pandemic diagnostic testing was not possible, was treated empirically under clinical suspicion of ML with good results.

Recurrent Lingual Abscess in an Elderly Female With Bulbar Amyotrophic Lateral Sclerosis.

A lingual abscess is a rare condition that was scarcely described in clinical textbooks. A lingual abscess recurrence is rare and has only been described twice in the literature. Typically, the tongue and oral cavity have multiple intrinsic properties which stave off intralingual infection; however, there may be situations in which these properties are compromised, as demonstrated in oro-motor disability. Lingual abscesses have the potential to develop into catastrophic obstructive airway issues; therefore, early detection and management are paramount. The following is a presentation of an elderly female with Bulbar Amyotrophic Lateral Sclerosis (ALS) treated conservatively for a lingual abscess with recurrence at eleven months post-treatment. Due to her baseline neuromuscular disorder and elevated anesthesia risk, she was treated in the interventional radiology suite with drain placement and Povidone-Iodine sclerotherapy under conscious sedation with excellent results.

Higher Readmission Rates After Hip Fracture Among Patients With Vestibular Disorders.

OBJECTIVE: Falls in older adults are associated with high morbidity and mortality. Patients with vestibular disorders may have an increased risk. The purpose of this study was to examine the outcomes among patients with underlying vestibular disorders who have hip fractures and identify predictors of increased morbidity and mortality. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care academic medical center. PATIENTS: Two hundred one adults diagnosed with a vestibular disorder and hip fracture due to a ground-level fall were compared to 327 age- and sex-matched controls with fractures due to ground-level falls without vestibular diagnoses. Patients were treated between 2013 and 2019. MAIN OUTCOME MEASURES: Length of hospital stay, 30-day readmission rate, and 30-day mortality rate. RESULTS: Thirty-day readmission rate after hip fracture was significantly increased in patients with vestibular disorders compared to matched controls (p < 0.001), odds ratio 3.12 (95% confidence interval 1.84-5.39). Reasons for readmission in the vestibular patient group included higher rates of repeat falls, infections, and recurrent vestibular symptoms. Use of medication classes associated with falls or hip fractures was not significantly different between groups, except for lower rates of antihypertensive use in the vestibular group (54.0% vs. 67.7%, p = 0.002). No significant difference was found for length of hospital stay (7.34 ±â€Š4.95 vs. 8.14 ±â€Š20.50 days, p = 0.51) or 30-day mortality rate (5.0% vs. 4.6%, p = 0.99). No significant differences were found between groups for age, sex, race, rate of surgical treatment for hip fracture, or disposition at discharge. CONCLUSIONS: Patients with vestibular disorders are at a significantly higher risk of hospital readmission within 30 days after discharge for treatment for hip fracture.

Progress in Confocal Laser Endomicroscopy for Neurosurgery and Technical Nuances for Brain Tumor Imaging With Fluorescein.

Background: Previous studies showed that confocal laser endomicroscopy (CLE) images of brain tumors acquired by a first-generation (Gen1) CLE system using fluorescein sodium (FNa) contrast yielded a diagnostic accuracy similar to frozen surgical sections and histologic analysis. We investigated performance improvements of a second-generation (Gen2) CLE system designed specifically for neurosurgical use. Methods: Rodent glioma models were used for in vivo and rapid ex vivo CLE imaging. FNa and 5-aminolevulinic acid were used as contrast agents. Gen1 and Gen2 CLE images were compared to distinguish cytoarchitectural features of tumor mass and margin and surrounding and normal brain regions. We assessed imaging parameters (gain, laser power, brightness, scanning speed, imaging depth, and Z-stack [3D image acquisition]) and evaluated optimal values for better neurosurgical imaging performance with Gen2. Results: Efficacy of Gen1 and Gen2 was similar in identifying normal brain tissue, vasculature, and tumor cells in masses or at margins. Gen2 had smaller field of view, but higher image resolution, and sharper, clearer images. Other advantages of the Gen2 were auto-brightness correction, user interface, image metadata handling, and image transfer. CLE imaging with FNa allowed identification of nuclear and cytoplasmic contours in tumor cells. Injection of higher dosages of FNa (20 and 40 mg/kg vs. 0.1-8 mg/kg) resulted in better image clarity and structural identification. When used with 5-aminolevulinic acid, CLE was not able to detect individual glioma cells labeled with protoporphyrin IX, but overall fluorescence intensity was higher (p < 0.01) than in the normal hemisphere. Gen2 Z-stack imaging allowed a unique 3D image volume presentation through the focal depth. Conclusion: Compared with Gen1, advantages of Gen2 CLE included a more responsive and intuitive user interface, collection of metadata with each image, automatic Z-stack imaging, sharper images, and a sterile sheath. Shortcomings of Gen2 were a slightly slower maximal imaging speed and smaller field of view. Optimal Gen2 imaging parameters to visualize brain tumor cytoarchitecture with FNa as a fluorescent contrast were defined to aid further neurosurgical clinical in vivo and rapid ex vivo use. Further validation of the Gen2 CLE for microscopic visualization and diagnosis of brain tumors is ongoing.

Travels to the tropics: Deutschtum and Fedor Krause's visits to Brazil.

Fedor Krause, the father of German neurosurgery, traveled to Latin America twice in the final years of his career (in 1920 and 1922). The associations and motivations for his travels to South America and his work there have not been well chronicled. In this paper, based on a review of historical official documents and publications, the authors describe Krause's activities in South America (focusing on Brazil) within the context of the Germanism doctrine and, most importantly, the professional enjoyment Krause reaped from his trips as well as his lasting influence on neurosurgery in South America. Fedor Krause's visits to Brazil occurred soon after World War I, when Germany sought to reestablish economic, political, cultural, and scientific power and influence. Science, particularly medicine, had been chosen as a field capable of meeting these needs. The advanced German system of academic organization and instruction, which included connections and collaborations with industry, was an optimal means to reestablish the economic viability of not only Germany but also Brazil. Krause, as a de facto ambassador, helped rebuild the German image and reconstruct diplomatic relations between Germany and Brazil. Krause's interactions during his visits helped put Brazilian neurosurgery on a firm foundation, and he left an indelible legacy of advancing professionalism and specialization in neurosurgery in Brazil.

Surgical Protocol for Infections, Nonhealing Wound Prophylaxis, and Analgesia: Development and Implementation for Posterior Spinal Fusions.

OBJECTIVE: To analyze the effects of a surgical protocol for infections, nonhealing wound prophylaxis, and analgesia among patients who underwent posterior spinal fusion at a single tertiary-care neurosurgical center. METHODS: This prospective study was conducted in the neurosurgery department of a tertiary-care neurosurgical center and compared a control group of patients who had posterior spinal fusion within 3 months before implementation of a surgical protocol with a study group of patients enrolled within 1 year after protocol implementation. The protocol included a surgical safety checklist, control of modifiable risks associated with surgical site infection, administration of intrawound vancomycin and local analgesia, and standard closure. Postoperative pain, demand for analgesics, and postoperative surgical site infections were assessed among patients before and after the introduction of the protocol. RESULTS: The control group (n = 35; 30 women; median age, 40 years [interquartile range, 31-54 years]) experienced a higher-than-predicted rate of minor surgical infections and nonhealing wounds (12 patients; 34%). In the study group (n = 113; 74 women; median age, 45 years [interquartile range, 37-54 years]), 11 patients (10%) had minor surgical infections and nonhealing wounds. Introduction of the protocol was associated with a 24% absolute risk reduction for minor surgical site infection and a significant decrease in pain on postoperative days 1 and 2 (P < 0.01 for both). Interpersonal communication improved among specialists involved in patient management. CONCLUSIONS: The protocol was effective in reducing postoperative pain and the rate of surgical site infection among patients with posterior spinal surgeries.

Microvascular anastomosis under 3D exoscope or endoscope magnification: A proof-of-concept study.

BACKGROUND: Extracranial-intracranial bypass is a challenging procedure that requires special microsurgical skills and an operative microscope. The exoscope is a tool for neurosurgical visualization that provides view on a heads-up display similar to an endoscope, but positioned external to the operating field, like a microscope. The authors carried out a proof-of-concept study evaluating the feasibility and effectiveness of performing microvascular bypass using various new exoscopic tools. METHODS: We evaluated microsurgical procedures using a three-dimensional (3D) endoscope, hands-free robotic automated positioning two-dimensional (2D) exoscope, and an ocular-free 3D exoscope, including surgical gauze knot tying, surgical glove cutting, placental vessel anastomoses, and rat vessel anastomoses. Image quality, effectiveness, and feasibility of each technique were compared among different visualization tools and to a standard operative microscope. RESULTS: 3D endoscopy produced relatively unsatisfactory resolution imaging. It was shown to be sufficient for knot tying and anastomosis of a placental artery, but was not suitable for anastomosis in rats. The 2D exoscope provided higher resolution imaging, but was not adequate for all maneuvers because of lack of depth perception. The 3D exoscope was shown to be functional to complete all maneuvers because of its depth perception and higher resolution. CONCLUSION: Depth perception and high resolution at highest magnification are required for microvascular bypass procedures. Execution of standard microanastomosis techniques was unsuccessful using 2D imaging modalities because of depth-perception-related constraints. Microvascular anastomosis is feasible under 3D exoscopic visualization; however, at highest magnification, the depth perception is inferior to that provided by a standard operative microscope, which impedes the procedure.

Confocal scanning microscopy provides rapid, detailed intraoperative histological assessment of brain neoplasms: Experience with 106 cases.

OBJECTIVES: Frozen section histological analysis is currently the mainstay for intraprocedural tissue diagnosis during the resection of intracranial neoplasms and for evaluating tumor margins. However, frozen sections are time-consuming and often do not reveal the histological features needed for final diagnosis when compared with permanent sections. Confocal scanning microscopy (CSM) with certain stains may be a valuable technology that can add rapid and detailed histological assessment advantage for the neurosurgical operating room. This study describes potential advantages of CSM imaging of fresh human brain tumor tissues labeled with acriflavine (AF), acridine orange (AO), cresyl violet (CV), methylene blue (MB), and indocyanine green (ICG) within the neurosurgical operating room facility. PATIENTS AND METHODS: Acute slices from orthotopic human intracranial neoplasms were incubated with AF/AO and CV solutions for 10 s and 1 min respectively. Staining was also attempted with MB and ICG. Samples were imaged using a bench-top CSM system. Histopathologic features of corresponding CSM and permanent hematoxylin and eosin images were reviewed for each case. RESULTS: Of 106 cases, 30 were meningiomas, 19 gliomas, 13 pituitary adenomas, 9 metastases, 6 schwannomas, 4 ependymomas, and 25 other pathologies. CSM using rapid fluorophores (AF, AO, CV) revealed striking microvascular, cellular and subcellular structures that correlated with conventional histology. By rapidly staining and optically sectioning freshly resected tissue, images were generated for intraoperative consultations in less than one minute. With this technique, an entire resected tissue sample was imaged and digitally stored for tele-pathology and archiving. CONCLUSION: CSM of fresh human brain tumor tissue provides clinically meaningful and rapid histopathological assessment much faster than frozen section. With appropriate stains, including specific cellular structure or antibody staining, CSM could improve the timeliness of intraoperative decision-making, and the neurosurgical-pathology workflow during resection of human brain tumors, ultimately improving patient care.

The role of therapeutic hypothermia in the management of acute spinal cord injury.

This review paper investigates the history, efficacy, and administration of systemic and local hypothermia for spinal cord injury (SCI). It summarizes the published experimental and clinical evidence on hypothermia for SCI and analyzes the potential for further research. Early experimental animal research showed that local hypothermia improved recovery and gain of function after acute SCI. However, in the early 1970s, clinical research findings did not coincide with results of these animal trials, which led to a loss of interest in local hypothermia. Since the 1980s, systemic hypothermia has been successfully used to treat SCI in both animals and humans. An abundance of positive evidence suggests that clinical trials are needed to determine the effectiveness of hypothermia for SCI. As a first step, we investigated the published clinical and experimental evidence on the use of hypothermia for SCI patients, who have few available treatment options. We searched PubMed for English-language reports published from 1940 to 2016 containing terms related to SCI treatment using hypothermia. We reviewed all articles on local hypothermia and acute SCI or on systemic hypothermia and acute SCI. Bibliographies of retrieved publications were also screened for additional citations. Ninety-six papers were selected. The clinical use of hypothermia is most successful if applied according to certain optimized parameters (e.g., duration, temperature, time from injury to initiation of cooling, and rewarming time). Preliminary data suggest that modest systemic hypothermia applied for 48h provides the best therapeutic value, but the parameters for use of local hypothermia vary greatly. Experimental evidence and some clinical evidence suggest that both local hypothermia and systemic hypothermia are beneficial for acute SCI. Future research should focus on defining the optimal levels of parameters. Large, multicenter, controlled clinical trials are needed to investigate its therapeutic potential.

Genetic Alterations in Intervertebral Disc Disease.

BACKGROUND: Intervertebral disc degeneration (IVDD) is considered a multifactorial disease that is influenced by both environmental and genetic factors. The last two decades of research strongly demonstrate that genetic factors contribute about 75% of the IVDD etiology. Recent total genome sequencing studies have shed light on the various single-nucleotide polymorphisms (SNPs) that are associated with IVDD. AIM: This review presents comprehensive and updated information about the diversity of genetic factors in the inflammatory, degradative, homeostatic, and structural systems involved in the IVDD. An organized collection of information is provided regarding genetic polymorphisms that have been identified to influence the risk of developing IVDD. Understanding the proteins and signaling systems involved in IVDD can lead to improved understanding and targeting of therapeutics. MATERIALS AND METHODS: An electronic literature search was performed using the National Library of Medicine for publications using the keywords genetics of IVDD, lumbar disc degeneration, degenerative disc disease, polymorphisms, SNPs, and disc disease. The articles were then screened based on inclusion criteria that included topics that covered the correlation of SNPs with developing IVDD. Sixty-five articles were identified as containing relevant information. Articles were excluded if they investigated lower back pain or just disc herniation without an analysis of disc degeneration. This study focuses on the chronic degeneration of IVDs. RESULTS: Various genes were identified to contain SNPs that influenced the risk of developing IVDD. Among these are genes contributing to structural proteins, such as COL1A1, COL9A3, COL9A3, COL11A1, and COL11A2, ACAN, and CHST3. Furthermore, various SNPs found in the vitamin-D receptor gene are also associated with IVDD. SNPs related to inflammatory cytokine imbalance are associated with IVDD, although some effects are limited by sex and certain populations. SNPs in genes that code for extracellular matrix-degrading enzymes, such as MMP-1, MMP-2, MMP-3, MMP-9, MMP-14, ADAMTS-4, and ADAMTS-5 are also associated with IVDD. Apoptosis-mediating genes, such as caspase 9 gene (CASP9), TRAIL, and death receptor 4 (DR4), as well as those for growth factors, such as growth differentiation factor 5 and VEGF, are identified to have polymorphisms that influence the risk of developing IVDD. CONCLUSION: Within the last 10 years, countless new SNPs have been identified in genes previously unknown to be associated with IVDD. Furthermore, the last decade has also revealed new SNPs identified in genes already known to be involved with increased risk of developing IVDD. Improved understanding of the numerous genetic variants behind various pathophysiological elements of IVDD could help advance personalized care and pharmacotherapeutic strategies for patients suffering from IVDD in the future.

The Role of microRNA Markers in the Diagnosis, Treatment, and Outcome Prediction of Spinal Cord Injury.

Spinal cord injury (SCI) is a devastating condition that affects many people worldwide. Treatment focuses on controlling secondary injury cascade and improving regeneration. It has recently been suggested that both the secondary injury cascade and the regenerative process are heavily regulated by microRNAs (miRNAs). The measurement of specific biomarkers could improve our understanding of the disease processes, and thereby provide clinicians with the opportunity to guide treatment and predict clinical outcomes after SCI. A variety of miRNAs exhibit important roles in processes of inflammation, cell death, and regeneration. These miRNAs can be used as diagnostic tools for predicting outcome after SCI. In addition, miRNAs can be used in the treatment of SCI and its symptoms. Significant laboratory and clinical evidence exist to show that miRNAs could be used as robust diagnostic and therapeutic tools for the treatment of patients with SCI. Further clinical studies are warranted to clarify the importance of each subtype of miRNA in SCI management.