The Role of Early Nd:YAG Laser Capsulotomy in Improving Visual Performance in Mild to Moderately Symptomatic Trifocal Patients.

Purpose: To determine the effect of early Nd:YAG (neodymium:yttrium-aluminum-garnet) laser capsulotomy on objective and subjective visual quality in symptomatic trifocal intraocular lens (IOL) patients. Methods: A single-center, prospective study examined symptomatic patients after bilateral cataract extraction with trifocal IOL implantation. A ten-question survey was conducted one month after surgery. Study endpoints included the assessment of monocular and binocular uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), contrast sensitivity (CS), and subjective visual quality before and after Nd:YAG capsulotomy prior to 4 months after cataract surgery. Results: A total of 38 eyes from 21 patients were included with a TFAT00 (n = 23) or TFAT30-60 (n = 15). Overall satisfaction with the IOL was 8.55 ± 1.77 (range 5-10). A Nd:YAG capsulotomy was performed at 55 ± 26 days. Monocular UDVA and UNVA > 20/25 before Nd:YAG were 53.0% and 42.0%, which improved post-Nd:YAG to 63.0% and 66.0%, respectively (P = 0.41, P = 0.051). Binocular UDVA and UNVA >20/25 before Nd:YAG were 82.0% and 63.0%, which increased to 97% and 97%, respectively (P < 0.05, P < 0.001). CS increased in all post-Nd:YAG capsulotomies (P < 0.01). The presence of glare was documented at 74% pre-Nd:YAG, which decreased to 41% post-Nd:YAG (P < 0.01). Glare which limited activities was documented at 24%, which decreased to 5% post-Nd:YAG (P = 0.21). Conclusion: Early treatment of posterior capsule opacities in mild to moderately dissatisfied trifocal IOL patients may be beneficial in improving CS, visual quality, and reducing the presence and severity of dysphotopsias.

Drip and Ship versus Mothership Model in the Middle Cerebral Artery Stroke: A Propensity-Matched Real-World Analysis Through National Inpatient Sample Data.

BACKGROUND: The superiority of mechanical thrombectomy and intravenous thrombolysis versus intravenous thrombolysis alone for acute ischemic stroke caused by large vessel occlusions has been established. This treatment can be organized into 2 models: drip and ship (DS) versus mothership (MS). We analyzed the National Inpatient Sample (NIS) data to compare the outcomes between these models in real-world settings. METHODS: NIS data were queried for 2017-2018 and propensity matching was used to match the differences. Outcomes for each group (disability at discharge and procedural complications) were compared. RESULTS: A total of 1226 patients were included in analysis (DS, n = 540; MS, n = 686) and groups were matched with respect to age, gender, and comorbidities. A total of 930 patients were included in the final analysis after propensity matching (DS, n = 465, MS, n = 465). The mean age in the DS group was 68.9 years (standard deviation [SD], 14.7) and 69.4 years (SD, 14) in the MS group (P = 0.752). The mean National Institutes of Health Stroke Scale score was 16.75 (SD, 6.07) in the DS group and 16.54 (SD, 5.99) in the MS group (P = 0.478). At discharge, minimal disability was noted in 22.4% in the DS group versus 26.2% in the MS group (P = 0.293). In-hospital mortality was lower in the MS group (8.8% vs. 7.1%; P = 0.32). The intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) rates were higher in the DS group (ICH, 24.3% vs. 18.7%; IVH, 2.4% vs. 0.9%) (ICH, P = 0.038; IVH, P = 0.068). CONCLUSIONS: Analyzing the efficacy and safety profile of DS versus MS models with the NIS database showed a trend toward better discharge outcomes and lower mortality for the MS group, although it did not reach statistical significance.

Primary Treatment of Small to Medium (<3 cm) Sporadic Vestibular Schwannomas: A Systematic Review and Meta-Analysis on Hearing Preservation and Tumor Control Rates for Microsurgery versus Radiosurgery.

BACKGROUND: A meta-analysis of patients with sporadic vestibular schwannoma (VS) primarily treated with stereotactic radiosurgery (SRS) or microsurgery (MS) was performed, and hearing preservation outcome (HPO), tumor control (TC), and facial nerve dysfunction (FND) were analyzed. METHODS: A systematic review was conducted (Medline and Scopus database) for the period January 2010-June 2020 with appropriate MeSH. English language articles for small to medium sporadic VS (<3 cm) using SRS or MS as primary treatment modality, with minimum follow-up of 3 years, were included. Studies had to report an acceptable standardized hearing metric. RESULTS: Thirty-two studies met the inclusion criteria: 10 MS; 23 radiosurgery, and 1 comparative study included in both. HPO, at approximately 65 months follow-up, were comparable between MS group (10 studies; 809 patients) and SRS group (23 studies; 1234 patients) (56% vs. 59%; P = 0.1527). TC, at approximately 70 months follow-up, was significantly better in the MS group (9 studies; 1635 patients) versus the SRS group (19 studies; 2260 patients) (98% vs. 92%; P < 0.0001). FND, at approximately 12 months follow-up, was significantly higher in the MS group (8 studies; 1101 patients) versus the SRS group (17 studies; 2285 patients) (10% vs. 2%; P < 0.0001). CONCLUSIONS: MS and SRS are comparable primary treatments for small (<3 cm) sporadic VS with respect to HPO at 5-year follow-up in patients with serviceable hearing at presentation; approximately 50% of patients for both modalities likely lose serviceable hearing by that time point. High TC rates (>90%) were seen with both modalities; MS 98% versus SRS 92%. The posttreatment FND was significantly less with the SRS group (2%) versus the MS group (10%).

"There's got to be a better way": Global Perspectives of Medicolegal Environment and Neurosurgical Socioeconomics.

Neurosurgery is considered to have one of the greatest risks of medical malpractice claims. However, medicolegal issues in neurosurgery are often disregarded and underrated worldwide. Medical errors in the neurosurgical field can be attributed to multiple factors, including highly morbid pathologies, the technical difficulty of neurosurgical procedures, and the involvement and interaction of a multidisciplinary team in the care of neurosurgical patients. Health care providers worldwide are at risk of lawsuits, sometimes even when no deviation from the standard of care had occurred in a given case. Often, governments use additional tactics to decrease the burden on compensators and extrajudicial institutions and to decrease the court's flow of irrational litigation. Continuous amendments to health care acts and newer reforms to address these issues have materialized worldwide. In the present narrative review, we have reviewed the global perspectives of medicolegal issues, with a focus on neurosurgical discipline.

The Medical Legal Environment in Neurosurgery: An Informative Overview of the Stages of Litigation and Distinct Challenges.

Medical malpractice litigation is something that every neurosurgeon encounters in his or her career and causes significant strife to amateur physicians attempting to navigate the medicolegal process. Neurosurgery in particular is one of the highest risk specialties for litigation. This calls to order the importance of a clear understanding of the medicolegal proceedings that may follow after a complaint has been filed. This report describes the steps to be taken by the physician in the instance that litigation is expected or considered a possibility. We describe the elements that comprise a medical malpractice claim, details of the lawsuit process including hospital peer review and expert witness selection, and how to communicate appropriately with the patients and their families in an empathetic way. It is imperative to gain an appropriate understanding of the entirety of the malpractice claim process to ease the anxiety of litigation for the physician and decrease the amount of avoidable complications.

Direct thrombectomy versus bridging thrombolysis with mechanical thrombectomy in middle cerebral artery stroke: a real-world analysis through National Inpatient Sample data.

OBJECTIVE: A paradigm shift in the management of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) occurred after 2015 when 7 randomized controlled trials demonstrated better outcomes using second-generation thrombectomy devices combined with best medical management than did stand-alone intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA). All recently published landmark trials were designed to study the outcome of mechanical thrombectomy (MT); therefore, the majority of the patients enrolled in these trials received intravenous tPA. Currently, initiating IVT before MT is a matter of debate. Recent trials (DIRECT-MT, DEVT) exploring this clinical question showed noninferiority of MT alone compared with the combined treatment. With this uncertainty, the authors aimed to explore real-world data through the latest National Inpatient Sample (NIS) to compare the safety and outcomes of MT alone with bridging IVT and MT in AIS due to LVO in the middle cerebral artery (MCA). METHODS: NIS data from 2017 to 2018 were analyzed to compare the outcomes and safety profiles of patients who underwent MT+IVT with those who underwent MT alone. RESULTS: A total of 2895 patients were included in the final analysis (MT, n = 1669; MT+IVT, n = 1226). The mean National Institutes of Health Stroke Scale score was 16.2 (SD 6.1) in the MT group and 16.6 (SD 5.97) in the MT+IVT group (p = 0.04). With respect to comorbidities, the two groups did not differ in rates of hypertension (p = 0.730), atrial fibrillation/flutter (p = 0.828), and smoking status (p = 0.914). The rate of diabetes mellitus was significantly higher in the MT group (28%) than in the MT+IVT group (22.1%) (p < 0.001). The frequency of intracerebral hemorrhage (ICH) in the MT group was 17.7% (n = 296) and 21.5% (n = 263) in the MT+IVT group (p = 0.012). Intraventricular hemorrhage (p = 0.875), subarachnoid hemorrhage (p = 0.99), and vasospasm (p = 0.976) did not differ significantly between the groups. The primary outcome considered was disability status between the groups; 23.8% of patients in the MT+IVT group had minimal disability versus 18.2% in the MT group (p = 0.001). The risk of progressing to severe disability from minimal disability decreased with the addition of IVT to MT (OR 0.762, 95% CI 0.637-0.912). The adjusted odds ratio for ICH in the MT+IVT group was 1.28 (95% CI 1.043-1.571, p = 0.018) and 2.676 (95% CI 1.259-5.686, p = 0.01) for access-site hemorrhages. CONCLUSIONS: In the analysis of the NIS database, the MT+IVT group had significantly higher rates of minimal disability at the time of hospital discharge versus the MT-alone group, despite a higher rate of ICH. The question of whether to treat patients with MT+IVT rather than MT alone is currently being addressed in ongoing prospective clinical trials (SWIFT-DIRECT [NCT03494920], MR CLEAN-NO IV [ISRCTN80619088], and DIRECT-SAFE [NCT03494920]). The results of these studies will contribute to greater understanding and progressive improvement in outcomes for AIS patients.

Venous Thromboembolism Prophylaxis in Elective Neurosurgery: A Survey of Board-Certified Neurosurgeons in the United States and Updated Literature Review.

BACKGROUND: Venous thromboembolism (VTE) remains the single most important preventable cause of morbidity and mortality following neurosurgical procedures, with an incidence of approximately 16%. In the absence of stringent guidelines, the variation in current practice patterns could be considerable and was the underlying basis for this study. OBJECTIVES: Our objective is to evaluate the modality of thromboprophylaxis used by neurosurgeons. METHODS: In line with "CHERRIES" (Checklist for Reporting Results of Internet E-Surveys) guidelines, an online survey regarding postoperative VTE prophylaxis following elective neurosurgical procedures was created using Google Forms and distributed to 1500 board-certified neurosurgeons in the United States. RESULTS: A total of 370 board-certified neurosurgeons (24.7%) responded to the survey. Sequential compression device was the only primary method of thromboprophylaxis used by 27.2% and 26.5% of respondents after elective craniotomy for tumor resection and spine surgery, respectively. Of the chemical prophylaxis, subcutaneous heparin 5000 U every 8 hours was the most commonly used medication followed by enoxaparin 40 mg daily. Most responders were comfortable starting chemical prophylaxis on postoperative day 1, followed by day 2 and day 3 in both types of surgeries. The mean postoperative time of chemical prophylaxis initiation was significantly more delayed by respondents with longer years in practice. CONCLUSIONS: This study highlights the variation in practice between neurosurgeons in managing postoperative VTE prophylaxis after elective spine and cranial surgeries. In lieu of this variation, our results showed that most neurosurgeons are comfortable starting chemical prophylaxis as soon as postoperative day 1 following both types of procedures.

Kv1.1 potassium channel subunit deficiency alters ventricular arrhythmia susceptibility, contractility, and repolarization.

Epilepsy-associated Kv1.1 voltage-gated potassium channel subunits encoded by the Kcna1 gene have traditionally been considered absent in heart, but recent studies reveal they are expressed in cardiomyocytes where they could regulate intrinsic cardiac electrophysiology. Although Kv1.1 now has a demonstrated functional role in atria, its role in the ventricles has never been investigated. In this work, electrophysiological, histological, and gene expression approaches were used to explore the consequences of Kv1.1 deficiency in the ventricles of Kcna1 knockout (KO) mice at the organ, cellular, and molecular levels to determine whether the absence of Kv1.1 leads to ventricular dysfunction that increases the risk of premature or sudden death. When subjected to intracardiac pacing, KO mice showed normal baseline susceptibility to inducible ventricular arrhythmias (VA) but resistance to VA under conditions of sympathetic challenge with isoproterenol. Echocardiography revealed cardiac contractile dysfunction manifesting as decreased ejection fraction and fractional shortening. In whole-cell patch-clamp recordings, KO ventricular cardiomyocytes exhibited action potential prolongation indicative of impaired repolarization. Imaging, histological, and transcript analyses showed no evidence of structural or channel gene expression remodeling, suggesting that the observed deficits are likely electrogenic due to Kv1.1 deficiency. Immunoblots of patient heart samples detected the presence of Kv1.1 at relatively high levels, implying that Kv1.1 contributes to human cardiac electrophysiology. Taken together, this work describes an important functional role for Kv1.1 in ventricles where its absence causes repolarization and contractility deficits but reduced susceptibility to arrhythmia under conditions of sympathetic drive.

Spinal Fractures in Ankylosing Spondylitis: Patterns, Management, and Complications in the United States - Analysis of Latest Nationwide Inpatient Sample Data.

OBJECTIVE: Ankylosing spondylitis (AS) is a rheumatic inflammatory disease marked by chronic inflammation of the axial skeleton. This condition, particularly when severe, can lead to increased risk of vertebral fractures attributed to decreased ability of the stiffened spinal column to sustain normal loads. However, little focus has been placed on understanding the locations of spinal fractures and associated complications and assessing the correlation between these. In this review, we aim to summarize the complications and treatment patterns in the United States in AS patients with spinal fractures, using the latest Nationwide Inpatient Sample (NIS) database (2016-2018). METHODS: We analyzed the NIS data of years 2016-2018 to compare the fracture patterns and complications. RESULTS: A total of 5,385 patients were included. The mean age was 71.63 years (standard deviation [SD], 13.21), with male predominance (83.8%). The most common population is Whites (77.4%), followed by Hispanics (7.9%). The most common fracture level was thoracic level (58.3%), followed by cervical level (38%). Multiple fracture levels were found in 13.3% of the patients. Spinal cord injury (SCI) was associated with 15.8% of the patients. The cervical level had a higher proportion of SCI (26.5%), followed by thoracic level (9.2%). The mean Elixhauser comorbidity score was 4.82 (SD, 2.17). A total of 2,365 patients (43.9%) underwent surgical treatment for the fractures. The overall complication rate was 40.8%. Respiratory complications, including pneumonia and respiratory insufficiency, were the predominant complications in the overall cohort. Based on the regression analysis, there was no significant difference (p = 0.45) in the complication rates based on the levels. The presence of SCI increased the odds of having a complication by 2.164 times (95% confidence interval, 1.722-2.72; p ≤ 0.001), and an increase in Elixhauser comorbidity score predicted the complication and in-hospital mortality rate (p ≤ 0.001). CONCLUSION: AS patients with spinal fractures have higher postoperative complications than the general population. The most common fracture location was thoracic in our study, although it differs with few studies, with SCI occurring in 1/6th of the patients.

Decreased bioavailability of hydrogen sulfide links vascular endothelium and atrial remodeling in atrial fibrillation.

Oxidative stress drives the pathogenesis of atrial fibrillation (AF), the most common arrhythmia. In the cardiovascular system, cystathionine γ-lyase (CSE) serves as the primary enzyme producing hydrogen sulfide (H2S), a mammalian gasotransmitter that reduces oxidative stress. Using a case control study design in patients with and without AF and a mouse model of CSE knockout (CSE-KO), we evaluated the role of H2S in the etiology of AF. Patients with AF (n = 51) had significantly reduced plasma acid labile sulfide levels compared to patients without AF (n = 65). In addition, patients with persistent AF (n = 25) showed lower plasma free sulfide levels compared to patients with paroxysmal AF (n = 26). Consistent with an important role for H2S in AF, CSE-KO mice had decreased atrial sulfide levels, increased atrial superoxide levels, and enhanced propensity for induced persistent AF compared to wild type (WT) mice. Rescuing H2S signaling in CSE-KO mice by Diallyl trisulfide (DATS) supplementation or reconstitution with endothelial cell specific CSE over-expression significantly reduced atrial superoxide, increased sulfide levels, and lowered AF inducibility. Lastly, low H2S levels in CSE KO mice was associated with atrial electrical remodeling including longer effective refractory periods, slower conduction velocity, increased myocyte calcium sparks, and increased myocyte action potential duration that were reversed by DATS supplementation or endothelial CSE overexpression. Our findings demonstrate an important role of CSE and H2S bioavailability in regulating electrical remodeling and susceptibility to AF.

Status of current medicolegal reform in the United States: a neurosurgical perspective.

OBJECTIVE: There are approximately 85,000 lawsuits filed against medical practitioners every year in the US. Among these lawsuits, neurosurgery has been identified as a "high-risk specialty" with exceptional chance of having medical malpractice suits filed. Major issues affecting the overall medicolegal environment include tort reform, the formation of medical review panels, the increasing practice of defensive medicine, and the rising costs of medical insurance. In this study, the authors provide a concise update of the current medicolegal environments of the 50 states and provide a general guide to favorable and unfavorable states in which to practice neurosurgery. METHODS: Data were acquired related to state-by-state medical review panel status, noneconomic damage caps, economic damage caps, and civil suit filing fees. States were placed into 5 categories based on the status of their current medicolegal environment. RESULTS: Of the 50 states in the US, 18 have established a medical review panel process. Fifteen states have a mandatory medical review process, whereas 3 states rely on a voluntary process. Thirty-five states have tort reform and have placed a cap on noneconomic damages. These caps range from $250,000 to $2,350,000, with the median cap of $465,900. Only 8 states have placed a cap on total economic damages. These caps range from $500,000 to $2,350,000, with the median cap of $1,050,000. All states have a filing fee for a medical malpractice lawsuit. These costs range from $37 to $884, with the median cost for filing of $335. CONCLUSIONS: Medicolegal healthcare reform will continue to play a vital role in physicians' lives. It will dictate if physicians may practice proactively or be forced to act defensively. With medicolegal reform varying greatly among states, it will ultimately dictate if physicians move into or away from certain states and thus guide the availability of healthcare services. A desirable legal system for neurosurgeons, including caps on economic and noneconomic damages and availability of medical review panels, can lead to safer practice.

Neuron-specific Kv1.1 deficiency is sufficient to cause epilepsy, premature death, and cardiorespiratory dysregulation.

Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related mortality, but the precise cellular substrates involved remain elusive. Epilepsy-associated ion channel genes with co-expression in brain and heart have been proposed as SUDEP candidate genes since they provide a singular unifying link between seizures and lethal cardiac arrhythmias. Here, we generated a conditional knockout (cKO) mouse with neuron-specific deletion of Kcna1, a SUDEP-associated gene with brain-heart co-expression, to test whether seizure-evoked cardiac arrhythmias and SUDEP require the absence of Kv1.1 in both brain and heart or whether ablation in neurons is sufficient. To obtain cKO mice, we developed a floxed Kcna1 mouse which we crossed to mice with the Synapsin1-Cre transgene, which selectively deletes Kcna1 in most neurons. Molecular analyses confirmed neuron-specific Kcna1 deletion in cKO mice and corresponding loss of Kv1.1 except in cerebellum where Synapsin1-Cre is not highly expressed. Survival studies and electroencephalography, electrocardiography, and plethysmography recordings showed that cKO mice exhibit premature death, epilepsy, and cardiorespiratory dysregulation but to a lesser degree than global knockouts. Heart rate variability (HRV) was increased in cKO mice with peaks during daytime suggesting disturbed diurnal HRV patterns as a SUDEP biomarker. Residual Kv1.1 expression in cKO cerebellum suggests it may play an unexpected role in regulating ictal cardiorespiratory dysfunction and SUDEP risk. This work demonstrates the principle that channelopathies with brain-heart expression patterns can increase death risk by brain-driven mechanisms alone without a functionally compromised heart, reinforcing seizure control as a primary clinical strategy for SUDEP prevention.

Deletion of the Cardiomyocyte Glucocorticoid Receptor Leads to Sexually Dimorphic Changes in Cardiac Gene Expression and Progression to Heart Failure.

Background The contribution of glucocorticoids to sexual dimorphism in the heart is essentially unknown. Therefore, we sought to determine the sexually dimorphic actions of glucocorticoid signaling in cardiac function and gene expression. To accomplish this goal, we conducted studies on mice lacking glucocorticoid receptors (GR) in cardiomyocytes (cardioGRKO mouse model). Methods and Results Deletion of cardiomyocyte GR leads to an increase in mortality because of the development of spontaneous cardiac pathology in both male and female mice; however, females are more resistant to GR signaling inactivation in the heart. Male cardioGRKO mice had a median survival age of 6 months. In contrast, females had a median survival age of 10 months. Transthoracic echocardiography data showed phenotypic differences between male and female cardioGRKO hearts. By 3 months of age, male cardioGRKO mice exhibited left ventricular systolic dysfunction. Conversely, no significant functional deficits were observed in female cardioGRKO mice at the same time point. Functional sensitivity of male hearts to the loss of cardiomyocyte GR was reversed following gonadectomy. RNA-Seq analysis showed that deleting GR in the male hearts leads to a more profound dysregulation in the expression of genes implicated in heart rate regulation (calcium handling). In agreement with these gene expression data, cardiomyocytes isolated from male cardioGRKO hearts displayed altered intracellular calcium responses. In contrast, female GR-deficient cardiomyocytes presented a response comparable with controls. Conclusions These data suggest that GR regulates calcium responses in a sex-biased manner, leading to sexually distinct responses to stress in male and female mice hearts, which may contribute to sex differences in heart disease, including the development of ventricular arrhythmias that contribute to heart failure and sudden death.

Genetic ablation or pharmacological inhibition of Kv1.1 potassium channel subunits impairs atrial repolarization in mice.

Voltage-gated Kv1.1 potassium channel α-subunits, encoded by the Kcna1 gene, have traditionally been regarded as neural-specific with no expression or function in the heart. However, recent data revealed that Kv1.1 subunits are expressed in atria where they may have an overlooked role in controlling repolarization and arrhythmia susceptibility independent of the nervous system. To explore this concept in more detail and to identify functional and molecular effects of Kv1.1 channel impairment in the heart, atrial cardiomyocyte patch-clamp electrophysiology and gene expression analyses were performed using Kcna1 knockout ( Kcna1-/-) mice. Specifically, we hypothesized that Kv1.1 subunits contribute to outward repolarizing K+ currents in mouse atria and that their absence prolongs cardiac action potentials. In voltage-clamp experiments, dendrotoxin-K (DTX-K), a Kv1.1-specific inhibitor, significantly reduced peak outward K+ currents in wild-type (WT) atrial cells but not Kcna1-/- cells, demonstrating an important contribution by Kv1.1-containing channels to mouse atrial repolarizing currents. In current-clamp recordings, Kcna1-/- atrial myocytes exhibited significant action potential prolongation which was exacerbated in right atria, effects that were partially recapitulated in WT cells by application of DTX-K. Quantitative RT-PCR measurements showed mRNA expression remodeling in Kcna1-/- atria for several ion channel genes that contribute to the atrial action potential including the Kcna5, Kcnh2, and Kcnj2 potassium channel genes and the Scn5a sodium channel gene. This study demonstrates a previously undescribed heart-intrinsic role for Kv1.1 subunits in mediating atrial repolarization, thereby adding a new member to the already diverse collection of known K+ channels in the heart.