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Objectives: The early recognition of sepsis and septic shock is crucial for improved patient outcomes. Quality improvement programs have ameliorated processes and outcomes in the care of patients with sepsis and septic shock. This study aimed to improve the proportion of patients receiving antibiotics within 1 hour of triage and compliance with sepsis bundles., Methods: A multidisciplinary sepsis task force was created to monitor and improve sepsis care. The program lasted 24 months from January 1, 2018, to December 31, 2019. A unique screening criterion was created by combining items from the systemic inflammatory response syndrome, quick sequential organ failure assessment, and National Early Warning Score systems. Thereafter, a sepsis flowsheet was implemented in the emergency department for monitoring. The measures between the first 12 months and the last 12 months were compared., Results: The proportion of patients receiving antibiotics within 1 hour of triage improved from 44% to 84%, intravenous crystalloid administration within 3 hours improved from 62% to 94%, serum lactic acid measurement within 3 hours improved from 62% to 94%, and vasopressor initiation within 6 hours improved from 76% to 94%. The mortality rates decreased from 32% to 21% between the 2 study periods., Conclusions: This program emphasizes the impact of a structured quality improvement program on the process and outcomes of care., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Extracellular vesicles (EVs) function as biomarkers and are crucial in cell communication and regulation, with therapeutic potential for intervertebral disc (IVD)-related low back pain (LBP). EV cargo is often affected by tissue health, which may affect the therapeutic potential. There is currently limited knowledge of how the cargo of IVD cell-derived EVs varies with tissue health and how differences in proteomic profile affect the predicted biological functions., Methods: Our study purified EVs from human IVD cell conditioned media by size-exclusion chromatography. Nanoparticle tracking analysis was conducted to measure EV size and concentration. Transmission electron microscopy and Western blot were performed to examine EV structure and markers. Tandem mass tag-mass spectrometry was conducted to determine protein cargo., Results: Most EVs were exosomes and intermediate microvesicles with an increasing amount linked to disease progression. Of the proteins detected, 88.6% were shared across the non-degenerate, mildly-degenerate, and degenerate samples. GO and KEGG analyses revealed that cargo from the mildly-degenerate samples was the most distinct, with the proteins in high abundance strongly associated with extracellular matrix (ECM) organization and structure. Shared proteins, highly expressed in the non-degenerate and degenerate samples, showed strong associations with cell adhesion, ECM-receptor interaction, and vesicle-mediated transport, respectively., Conclusions: Our findings indicate that EVs from IVD cells from tissue with different degrees of degeneration share a majority of the cargo proteins. However, the level of expression differs with degeneration grade. Cargo from the mildly-degenerate samples exhibits the most differences. A better understanding of changes in EV cargo in the degenerative process may provide novel information related to molecular mechanisms underlying IVD degeneration and suggest new potential treatment modalities for IVD-related LBP., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). JOR Spine published by Wiley Periodicals LLC on behalf of Orthopaedic Research Society.)

Background: Postsurgical kyphosis is relatively common in children who have undergone resection of intramedullary spinal cord tumors. Progressive kyphosis almost always requires instrumentation and fusion surgery, which can delay or interfere with adjuvant oncological treatments and can deleteriously impact the long-term performance status of the patient., Observations: Here, the authors report a case of near-complete spontaneous recovery (i.e., without spinal fusion surgery) of postsurgical progressive cervical spine kyphosis following intramedullary spinal cord tumor resection and discuss the potential factors that may have contributed to this positive outcome., Lessons: This case serves as a reminder that spontaneous recovery from postsurgical progressive cervical spine kyphosis can occur and that some patients (i.e., those without neurological deficits) can be monitored closely, with a watch-and-wait approach, before subjecting them to additional surgical risks, delays in other treatments, and potential morbidity. https://thejns.org/doi/10.3171/CASE24187.

Background and Objectives: Hyponatraemia increases the morbidity and mortality risks of orthopaedic patients. When undergoing spine surgery, hyponatraemic patients have high risks of pneumonia and of staying in hospital for up to 1 day longer compared with non-hyponatraemic patients. This study aims to assess the occurrence of adverse events among patients with pre-operative hyponatraemia after undergoing lumbar surgery., Materials and Methods: A retrospective cohort study was conducted. Patients who underwent spinal surgery in 2011 to 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate analysis was conducted to demonstrate the difference in post-operative complication rates between hyponatraemic patients and normonatraemic patients. Post-operative adverse events, need for blood transfusion and length of stay were considered as clinical outcome data., Results: A total of 58,049 patients were included; pre-operatively, 55,012 (94.8%) were normonatraemic and 3037 (5.2%) were hyponatraemic. Multivariate analysis showed that hyponatraemic patients had higher rates of adverse events, blood transfusions and urinary tract infections. Specifically, 632 (20.8%) hyponatraemic patients developed adverse events, compared with 6821 (12.4%) normonatraemic patients; the hyponatraemic patients received transfusions, compared with 6821 (7.4%) normonatraemic patients; and 97 (3.2%) hyponatraemic patients developed urinary tract infections, compared with 715 (1.3%) normonatraemic patients. Finally, an extended length of stay beyond 6 days occurred in 604 (19.9%) hyponatraemic patients, compared with 4676 (8.5%) normonatraemic patients., Conclusions: Our study identified an association between pre-operative hyponatraemia and post-operative adverse events in spinal surgery patients. However, it is unclear whether hyponatraemia caused the higher adverse event rate., Competing Interests: The authors declare no conflicts of interest. All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.

Background: Unilateral laminotomy with bilateral spinal canal decompression has gained popularity recently., Aim: To systematically review the literature of unilateral laminotomy with bilateral spinal canal decompression for lumbar spinal stenosis (LSS) aiming to assess outcomes and complications of the different techniques described in literature., Methods: On August 7, 2022, Pubmed and EMBASE were searched by 2 reviewers independently, and all the relevant studies published up to date were considered based on predetermined inclusion and exclusion criteria. The subject headings "unilateral laminotomy", "bilateral decompression" and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles., Results: A total of seven studies including 371 patients were included. The mean age of the patients was 69.0 years (range: 55-83 years). The follow up duration ranged from 1 to 3 years. Rate of postoperative pain and functional improvement was favorable based on VAS, JOA, JOABPEQ, RMDW, ODI and SF-36, for example improved from a range of 4.2-7.5 preoperatively on the VAS score to a range of 1.4-3.0 postoperatively at the final follow up. Insufficient decompression was noted in 3% of the reported cases. The overall complication rate was reported at 18-20%, with dural tear at 3.6-9% and hematoma at 0-4%., Conclusion: Unilateral laminotomy with bilateral decompression has favorable short- and mid-term pain and functional outcomes with low recurrence and complication rates. This, however, needs to be further confirmed in larger, long-term follow-up, prospective, comparative studies between open, and minimally invasive techniques., (© 2023. The Author(s).)

Objective: Delayed cerebral ischemia (DCI) associated with vasospasm is well described in the setting of aneurysmal subarachnoid hemorrhage (SAH). In addition, DCI is very infrequently encountered in patients who have undergone resection of a brain tumor with unclear pathophysiology. The occurrence of DCI in the pediatric population is exceedingly rare, and outcomes in this population have, to the authors' knowledge, never been systematically reviewed. Therefore, the authors present what is to their knowledge the largest series of pediatric patients with this complication and systematically reviewed the literature for individual participant data., Methods: The authors conducted a retrospective review of 172 sellar and suprasellar tumors in pediatric patients who underwent surgery at the Montreal Children's Hospital between 1999 and 2017 to identify cases of vasospasm occurring after tumor resection. Descriptive statistics, including patient characteristics, intraoperative and postoperative findings, and outcome status, were collected. A systematic review was also conducted using three databases (PubMed, Web of Science, Embase) to identify reported cases available in the literature of vasospasm after tumor resection in children and collect individual participant data on these patients for further analysis., Results: Six patients treated at Montreal Children's Hospital were identified, with an average age of 9.5 years (range 6-15 years). The prevalence of vasospasm after tumor resection was 3.5% (6/172). Vasospasm in all 6 patients occurred after craniotomy was performed to treat a suprasellar tumor. The average interval from surgery to symptoms was 3.25 days (range 12 hours-10 days). The most common tumor etiology was craniopharyngioma, seen in 4 cases. Extensive tumor encasement of blood vessels requiring significant operative manipulation was described in all 6 patients. A rapid decrease in serum sodium (exceeding 12 mEq/L/24 hrs or below 135 mEq/L) was seen in 4 patients. On final follow-up, 3 patients were left with significant disability, and all patients had persistent deficits. A systematic review of the literature revealed a total of 10 other patients whose characteristics and treatment were compared with those of the 6 patients treated at Montreal Children's Hospital., Conclusions: Vasospasm after tumor resection in children and youth is likely a rare entity, with a prevalence of 3.5% in this case series. Suprasellar tumor location (particularly craniopharyngioma tumor etiology), significant encasement of blood vessels by the tumor, and postoperative hyponatremia may be predictive factors. Outcome is poor, with most patients having significant persistent neurological deficits.

Background: Degenerative cervical myelopathy (DCM) is a progressive neurologic condition caused by age-related degeneration of the cervical spine. Social media has become a crucial part of many patients' lives; however, little is known about social media use pertaining to DCM., Objective: This manuscript describes the landscape of social media use and DCM in patients, caretakers, clinicians, and researchers., Methods: A comprehensive search of the entire Twitter application programing interface database from inception to March 2022 was performed to identify all tweets about cervical myelopathy. Data on Twitter users included geographic location, number of followers, and number of tweets. The number of tweet likes, retweets, quotes, and total engagement were collected. Tweets were also categorized based on their underlying themes. Mentions pertaining to past or upcoming surgical procedures were recorded. A natural language processing algorithm was used to assign a polarity score, subjectivity score, and analysis label to each tweet for sentiment analysis., Results: Overall, 1859 unique tweets from 1769 accounts met the inclusion criteria. The highest frequency of tweets was seen in 2018 and 2019, and tweets decreased significantly in 2020 and 2021. Most (888/1769, 50.2%) of the tweets' authors were from the United States, United Kingdom, or Canada. Account categorization showed that 668 of 1769 (37.8%) users discussing DCM on Twitter were medical doctors or researchers, 415 of 1769 (23.5%) were patients or caregivers, and 201 of 1769 (11.4%) were news media outlets. The 1859 tweets most often discussed research (n=761, 40.9%), followed by spreading awareness or informing the public on DCM (n=559, 30.1%). Tweets describing personal patient perspectives on living with DCM were seen in 296 (15.9%) posts, with 65 (24%) of these discussing upcoming or past surgical experiences. Few tweets were related to advertising (n=31, 1.7%) or fundraising (n=7, 0.4%). A total of 930 (50%) tweets included a link, 260 (14%) included media (ie, photos or videos), and 595 (32%) included a hashtag. Overall, 847 of the 1859 tweets (45.6%) were classified as neutral, 717 (38.6%) as positive, and 295 (15.9%) as negative., Conclusions: When categorized thematically, most tweets were related to research, followed by spreading awareness or informing the public on DCM. Almost 25% (65/296) of tweets describing patients' personal experiences with DCM discussed past or upcoming surgical interventions. Few posts pertained to advertising or fundraising. These data can help identify areas for improvement of public awareness online, particularly regarding education, support, and fundraising., (©Lior M Elkaim, Jordan J Levett, Farbod Niazi, Mohammed A Alvi, Nathan A Shlobin, Joseph R Linzey, Faith Robertson, Rakan Bokhari, Naif M Alotaibi, Oliver Lasry. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.05.2023.)

Introduction: Delayed cerebral ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. There is little high-quality evidence available to guide the management of DCI. The Canadian Neurosurgery Research Collaborative (CNRC) is comprised of resident physicians who are positioned to capture national, multi-site data. The objective of this study was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI., Methods: We performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. A 19-question electronic survey (Survey Monkey) was developed and validated by the CNRC following a DCI-related literature review (PubMed, Embase). The survey was distributed to members of the Canadian Neurosurgical Society and to Canadian members of the Neurocritical Care Society. Responses were analyzed using quantitative and qualitative methods., Results: The response rate was 129/340 (38%). Agreement among respondents was limited to the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for the prevention of DCI. Several inconsistencies were identified. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients who felt to require IV milrinone, IA vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI., Conclusion: DCI is an important clinical entity for which no homogeneity and standardization exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the definition, identification, and treatment of DCI.

Land subsidence is considered a threat to developing cities and is triggered by several natural (geological and seismic) and human (mining, groundwater withdrawal, oil and gas extraction, constructions) factors. This research has gathered datasets consisting of 80 Sentinel-1A ascending and descending SLC images from July 2017 to July 2019. This dataset, concerning InSAR and PS-InSAR, is processed with SARPROZ software to determine the land subsidence in Gwadar City, Balochistan, Pakistan. Later, the maps were created with ArcGIS 10.8. Due to InSAR's limitations in measuring millimeter-scale surface deformation, Multi-Temporal InSAR techniques, like PS-InSAR, are introduced to provide better accuracy, consistency, and fewer errors of deformation analysis. This remote-based SAR technique is helpful in the Gwadar area; for researchers, city mobility is constrained and has become more restricted post-Covid-19. This technique requires multiple images acquired of the same place at different times for estimating surface deformation per year, along with surface uplifting and subsidence. The InSAR results showed maximum deformation in the Koh-i-Mehdi Mountain from 2017 to 2019. The PS-InSAR results showed subsidence up to -92 mm/year in ascending track and -66 mm/year in descending track in the area of Koh-i-Mehdi Mountain, and up to -48 mm/year in ascending track and -32 mm/year in descending track in the area of the deep seaport. From our experimental results, a high subsidence rate has been found in the newly evolving Gwadar City. This city is very beneficial to the country's economic development because of its deep-sea port, developed by the China-Pakistan Economic Corridor (CPEC). The research is associated with a detailed analysis of Gwadar City, identifying the areas with significant subsidence, and enlisting the possible causes that are needed to be resolved before further developments. Our findings are helpful to urban development and disaster monitoring as the city is being promoted as the next significant deep seaport with the start of CPEC., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors.)

As new molecular tracers are identified to target specific receptors, tissue, and tumor types, opportunities arise for the development of both diagnostic tracers and their therapeutic counterparts, termed "theranostics." While diagnostic tracers utilize positron emitters or gamma-emitting radionuclides, their theranostic counterparts are typically bound to beta and alpha emitters, which can deliver specific and localized radiation to targets with minimal collateral damage to uninvolved surrounding structures. This is an exciting time in molecular imaging and therapy and a step towards personalized and precise medicine in which patients who were either without treatment options or not candidates for other therapies now have expanded options, with tangible data showing improved outcomes. This manuscript explores the current state of theranostics, providing background, treatment specifics, and toxicities, and discusses future potential trends., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Anatomic studies have suggested that the central insular sulcus (CIS) runs in line with the Rolandic sulcus (RS). The radiographic relationship between the RS and CIS has not been systematically studied. This study aims to evaluate the applicability of using the CIS as a radiologic landmark to identify the RS., Methods: We retrospectively reviewed 100 consecutive normal magnetic resonance imaging (MRI) scans (200 hemispheres) performed at a single institution. MRI scans with any intracranial pathology or finding were excluded. Sagittal and axial fluid-attenuated inversion recovery sequences were used in this study. Two evaluators independently evaluated the relationship of the CIS and RS in all MRI scans. A predefined 3-step method was then used to identify the CIS, RS, and hand motor area in sagittal and axial images., Results: The CIS was found to be correlated with the RS in 191 hemispheres (95.5%). In the remaining 9 hemispheres, the postcentral sulcus represented the most correlated sulcus with the CIS (7 hemispheres). The interrater agreement was 0.673 (P < 0.05), indicating a substantial agreement. The hand motor area was identified in the same section as the CIS in 175 hemispheres (87.5%)., Conclusions: The CIS is a highly reliable radiographic landmark for the identification of the RS. The hand motor area can also be identified reliably using this method., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: This study aims to glean patient and caregiver perspectives surrounding deep brain stimulation (DBS) in children and youth through an analysis of patterns of social media usage., Methods: The authors performed a comprehensive search of the Twitter Application Programming Interface (API) database for all tweets about DBS use in children and youth, with no date restriction. Data pertaining to each tweet were extracted for analysis. Results were analyzed using qualitative and quantitative methodologies. These included thematic analysis of tweets, accounts, and descriptive statistics. Sentiment analysis of extracted tweets was also performed. A multivariable regression model was used to identify predictors of higher engagement metrics (likes, retweets, and quotes)., Results: A comprehensive search of the Twitter database yielded 877 tweets from 816 unique accounts meeting study inclusion criteria. Most tweets were from patients or caregivers, researchers, or news media outlets. The most common themes among analyzed tweets were research discussing novel findings (45.2%) or personal experiences of patients or caregivers (27.4%). Sentiment analysis showed that 54.5% of tweets were positive, 35.1% were neutral, and 10.4% were negative. The presence of pictures or videos increased the tweet engagement count by an average of 10.5 (95% CI 7.3-13.6). Tweets about personal patient experiences (β = 6, 95% CI 0.95-12) and tweets tagging other accounts (β = 3.2, 95% CI 0.63-5.8) were also significantly associated with higher engagement metrics., Conclusions: The current study is the first to assess patient and caregiver perspectives surrounding pediatric DBS through a comprehensive analysis of social media usage. Given the nascent field, social media presents an opportunity to share experiences and promote patient and healthcare professional education surrounding pediatric DBS.

Novel anticancer agents have replaced conventional chemotherapy as first line agents for many cancers, with continued new and expanding indications. Small molecule inhibitors act on cell surface or intracellular targets and prevent the downstream signaling that would otherwise permit tumor growth and spread. Anticancer antibodies can be directed against growth factors or may be immunotherapeutic agents. The latter act by inhibiting mechanisms that cancer cells use to evade the immune system. Hormonal agents act by decreasing levels of hormones that are necessary for the growth of certain cancer cells. Cancer therapy protocols often include novel anticancer agents and conventional chemotherapy used successively or in combination, in order to maximize survival and minimize morbidity. A working knowledge of anti-cancer drug classification will aid the radiologist in assessing response on imaging., (© 2022 The Authors.)

Studies show an association between cadmium (Cd) exposure and prediabetes or type II diabetes mellitus. We have previously reported that Cd causes decreased levels of serum leptin in rats following 12 weeks of daily Cd dosing (0.6 mg/kg/b.w./day). Since leptin plays an important role in metabolism, we examined the effects of Cd on rats and db/db mice, which are deficient in leptin receptor activity. We gave rats and mice daily subcutaneous injections of saline (control) or CdCl 2 at a dose of 0.6 mg/kg of Cd for 2 weeks, followed by 2 weeks of no dosing. At the end of the 4-week study, exposure to Cd resulted in a more rapid increase in blood glucose levels following an oral glucose tolerance test in db/db vs. lean mice. During the two weeks of no Cd dosing, individual rat bodyweight gain was greater ( p ≤ 0.05) in Cd-treated animals. At this time point, the combined epididymal and retroperitoneal fat pad weight was significantly greater ( p ≤ 0.05) in the Cd-treated lean mice compared to saline-treated controls. Although this pilot study had relatively low N values (4 per treatment group for mice and 6 for rats) the results show that clinically relevant levels of Cd exposure resulted in diabetogenic as well as obesogenic effects.

Amputation of the mouse digit tip results in blastema-mediated regeneration. In this model, new bone regenerates de novo to lengthen the amputated stump bone, resulting in a functional replacement of the terminal phalangeal element along with associated non-skeletal tissues. Physiological examples of bone repair, such as distraction osteogenesis and fracture repair, are well known to require mechanical loading. However, the role of mechanical loading during mammalian digit tip regeneration is unknown. In this study, we demonstrate that reducing mechanical loading inhibits blastema formation by attenuating bone resorption and wound closure, resulting in the complete inhibition of digit regeneration. Mechanical unloading effects on wound healing and regeneration are completely reversible when mechanical loading is restored. Mechanical unloading after blastema formation results in a reduced rate of de novo bone formation, demonstrating mechanical load dependence of the bone regenerative response. Moreover, enhancing the wound-healing response of mechanically unloaded digits with the cyanoacrylate tissue adhesive Dermabond improves wound closure and partially rescues digit tip regeneration. Taken together, these results demonstrate that mammalian digit tip regeneration is mechanical load-dependent. Given that human fingertip regeneration shares many characteristics with the mouse digit tip, these results identify mechanical load as a previously unappreciated requirement for de novo bone regeneration in humans. © 2021 American Society for Bone and Mineral Research (ASBMR)., (© 2021 American Society for Bone and Mineral Research (ASBMR).)

Rett syndrome is a neurodevelopmental genetic X-linked disorder. It is predominantly found in females with a prevalence rate of 1 : 9000. Rett syndrome patients are usually healthy the first months of their lives. The syndrome goes into a deceleration phase where motor, behavioral, and cognitive skills are impaired. Regarding their oral health, bruxism is one of the common oral manifestations found among Rett syndrome patients. We present a case of an 8-year-old patient with Rett syndrome who presented to the dental clinic for oral rehabilitation. The patient was evaluated and treated under general anesthesia with multiple extractions, restorations, and crown installments. Oral rehabilitation of Rett syndrome is important for those patients, and proper evaluation and treatment are the most efficient when performed under general anesthesia., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wisam Al-Hathlol et al.)

Abstract: Surgical site infections (SSIs) are common complications after spinal surgery that result in increased morbidity, mortality, and healthcare costs. It was estimated that SSIs after spinal surgery resulted in a 4-fold increase in health care costs. The reported SSI rate following spinal surgery remains highly variable between approximately 0.5% and 18%. In this study, we aimed to estimate the SSI rate and identify possible risk factors for SSI after spinal surgery in our Saudi patient population.We conducted a single-center, retrospective case-control study in Saudi Arabia that included patients who developed SSIs, while the controls were all consecutive patients who underwent spinal surgery between January 2014 and December 2016. We extracted data on patient characteristics, anthropometric measurements, preoperative laboratory investigations, preoperative infection prevention measures, intraoperative measures, comorbidities, and postoperative care.We included 201 consecutive patients in our study; their median age was 56.9 years, and 51.2% were men. Only 4% (n = 8) of these patients developed SSIs postoperatively. Postoperative SSIs were significantly associated with longer postoperative hospital stays, hypertension, higher American Society of Anesthesia (ASA) scores, longer procedure durations, and the use of a greater number of blood transfusion units.This study revealed a low SSI rate following spinal surgery. We identified a history of hypertension, prolonged hospitalization, longer operative time, blood transfusion, and higher ASA score as risk factors for SSI in spine surgery in our population. As our findings are from a single institute, we believe that a national research collaboration among multiple disciplines should be performed to provide better estimates of SSI risk factors in our patient population., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Dural venous sinus thrombosis (DVST) is an increasingly recognized complication of blunt traumatic brain injury (TBI) and skull fractures. However, data concerning epidemiology and clinical significance of DVST are unclear. Determining the disease burden in patients with TBI is an important first step to guide future studies assessing the natural course of traumatic DVST or the effects of its treatment. Therefore, we performed to our knowledge the first systematic review and meta-analysis evaluating the prevalence of DVST in patients with TBI and skull fractures., Methods: MEDLINE and Embase databases were systematically searched for relevant studies published up to March 2018. All studies that assessed the prevalence of DVST among patients with TBI who underwent a vascular imaging study were included. The primary outcome was the presence or absence of DVST on imaging. A random-effects meta-analysis was used to pool studies., Results: Our systematic review yielded 638 articles, and 13 articles met inclusion criteria. In patients with skull fractures adjacent to a venous sinus, the prevalence was 26.2% (95% confidence interval = 19.4%-34.4%). This elevated risk was similar between adult (pooled estimate 23.8%; 95% CI = 16.2%-33.5%) and pediatric (pooled estimate 31.3%; 95% CI = 19.1%-46.9%) populations., Conclusions: We found an unexpectedly high and consistent frequency of DVST among patients with skull fractures regardless of age group or severity of brain injury. These findings are important and highlight the need for further understanding the natural history of DVST and providing better guidelines on its management., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Epidermoid cysts are slow-growing extra-axial lesions that account for approximately 1% of all brain tumors. They rarely occur in the brain stem, and those possessing both intra-axial as well as extra-axial components represent an even smaller subset., Case Description: We report the unusual manifestation of 2 adult male patients, whose recurrent posterior fossa epidermoid cysts progressively invaded the anterior surface of the pons. Over the years, the patients would present with various complaints of ataxia, diplopia, facial spasms, and hearing loss and underwent several interventions for recurrence. Eventually, the epidermoid cysts progressed to completely split the pons, forming a surgical corridor that was amenable to a posterior approach. We describe the patients' favorable clinical courses, pathologic and neuroradiologic findings, as well as review the literature for similar such cases., Conclusions: To the best of our knowledge, there are only 8 other cases of brainstem epidermoid lesions reported in the literature that are presumed to have originated extrinsically and thereafter transgressed the pons. However, we are the first to provide radiographic documentation confirming the progression of the lesions from extra-axial to intraparenchymal. Furthermore, although clinically subtle, we have decided to coin the term "split-pons syndrome" to better define this radiologic entity. Based on the evolution of the epidermoid's growth pattern, the authors propose a delayed posterior approach (telo-velo-tonsillar) to minimize morbidity., (Copyright © 2019. Published by Elsevier Inc.)

Background: Applying vancomycin into the surgical site has been well-described in spinal neurosurgery, with extensive institutional experience and systematic reviews describing its effectiveness in reducing surgical site infections (SSIs). Its use in nonspinal neurosurgical procedures is a logical extension of those findings; however, recent studies have described varying degrees of success. We have summarized the effect of local vancomycin application on SSIs in nonspinal neurosurgical procedures and describe the quality of the supporting evidence., Methods: MEDLINE, Embase, and Google Scholar were searched through June 2018. Information on study design, demographic data, exposure, and outcomes was extracted. The estimates were combined using random-effects models., Results: Our search retrieved 9 studies for quantitative analysis. They assessed vancomycin use in craniotomy, cranioplasty, deep brain stimulator-related procedures, and ventriculoperitoneal shunt surgery. Most of the studies had serious methodological shortcomings that introduced confounding. We found an overall beneficial effect on SSI incidence (odds ratio, 0.25; 95% confidence interval, 0.12-0.52), which was seen across all subspecialties, except for cranioplasty. The use of vancomycin did not result in the emergence of resistant infections or in a significant increase in the proportion of infections caused by gram-negative organisms., Conclusions: Vancomycin use in nonspinal neurosurgery is not supported by high-quality evidence, limiting the strength of the conclusions that can be drawn on the topic. Nonetheless, we found an overall favorable effect on SSIs (except in the context of cranioplasty), which should be reproduced in a randomized controlled fashion., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Spontaneous spinal epidural hematoma (SSEH) is a rare and morbid entity, with the prognosis affected by delayed diagnosis and surgical intervention. The correlation between the timing of the intervention and neurological recovery has not been clearly reported. We present a retrospective study of SSEH to determine the correlation between the timing of surgical intervention and changes in the spinal cord signal on magnetic resonance imaging (MRI) with the neurological outcome., Methods: The records of 14 patients who had undergone surgical decompression of SSEHs during a 10-year duration were reviewed. The diagnosis was established from the MRI, intraoperative, and histopathological examination findings., Results: We identified 14 patients from both centers, 6 of whom were male. Their mean age was 54.1 years. The onset was spontaneous, and 2 patients were receiving anticoagulant therapy. The most common presentation was paraplegia (n = 8), followed by paraparesis (n = 3) and quadriparesis (n = 2). Spinal cord signal changes were demonstrated on all T2-weighted MRI studies. The response to surgery was favorable for 13 of our patients at the 6-month follow-up examination. The spinal cord changes had persisted in 5 patients on the 6-month postoperative MRI scan. All 14 patients, except for 1, had a favorable neurological outcome at the last follow-up examination., Conclusions: Significant neurological recovery after surgical decompression of SSEHs can be achieved, despite the significant preoperative neurological deficits, spinal cord changes on MRI, and delayed timing of intervention., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Stand-alone cervical laminectomy for degenerative cervical myelopathy (DCM) has become increasingly rare due to risk of postlaminectomy kyphosis. This article discusses the biomechanics of cervical degeneration and how laminectomy effects spine stability, and summarizes relevant clinical studies to help guide surgical decision-making for the posterior treatment of DCM. Laminectomy and fusion remains a safe and efficacious treatment. Stand-alone laminectomy should only be used for a highly selected patient population with relative stiff lordotic cervical spines, using care to not disrupt facets and C2 and C7 muscle attachments., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The acquisition of intravenous (IV) access in the actively convulsing patient is difficult. This often delays the administration of the IV benzodiazepine (BDZ) necessary for seizure cessation. Delays in seizure cessation are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes, and increased morbidity., Objective: The objective was to assess whether the delay imposed by IV access acquisition is justified by improved outcomes. We compared IV versus non-IV BDZ efficacy in the real world with regard to failure rates (primary outcome), interval to seizure control, and observed complications (secondary outcomes)., Methods: A systematic review was performed using Medline, Embase, and the Cochrane Library. All studies published or in press from the inception of the respective database to July 2016 were included. Only randomized and quasi-randomized controlled trials directly comparing IV to non-IV (buccal, rectal, intranasal, or intramuscular) BDZ were included., Results: Our search strategy retrieved 2,604 citations for review. A total of 11 studies were finally included in qualitative synthesis and 10 in quantitative analysis. Only one was of high quality. For treatment failure, non-IV BDZ was superior to IV BDZ (odd ratio [OR] = 0.72; 95% confidence interval [CI] = 0.56-0.92). However, no significant difference was found between the two treatments in the pediatric subgroup (OR = 1.16; 95% CI = 0.74-1.81). Non-IV BDZ was administered faster than IV BDZ and therefore controlled seizures faster (mean difference = 3.41 minutes; 95% CI = 1.69-5.13 minutes) despite a longer interval between drug administration and seizure cessation (mean difference = 0.74 minutes; 95% CI = 0.52-0.95 minutes). Respiratory complications requiring intervention were similar between non-IV BDZ and IV BDZ, regardless of administration route (risk difference = 0.00; 95% CI = -0.02 to 0.01)., Conclusion: Non-IV BDZ, compared to IV BDZ, terminate seizures faster and have a superior efficacy and side effect profile. Higher-quality studies and further evaluation in different age groups are warranted., (© 2017 by the Society for Academic Emergency Medicine.)

Link N (DHLSDNYTLDHDRAIH) is a peptide that occurs naturally in the intervertebral discs (IVDs) and cartilage as a result of proteolytic cleavage of Link protein. Several studies have identified Link N as a growth factor capable of stimulating matrix synthesis in these tissues. We have recently discovered that annulus fibrosus cells can release an enzyme (possibly cathepsin K) that can further cleave Link N resulting in an eight amino acid peptide, we called short Link N (sLink N). Separately, we recently developed and validated an organ culture model that has the vertebrae attached (vIVDs; IVD with intact vertebrae). The aims of this study were (i) to examine if sLink N has the potential to repair early degenerate discs and (ii) to determine if this new model can be used to test potential drugs for disc repair. To determine if sLink N was able to stimulate repair of the degenerate disc, vIVDs with trypsin-induced degeneration (DG) were used. After 4 weeks of culture, the proteoglycan content measured as glycosaminoglycans was stimulated by sLink N in the degenerated discs, and the staining of proteoglycan was observed throughout the tissue irrespective of its proximity to the cells. The quantity of extractable type II collagen and aggrecan was also increased when the degenerate discs were treated with sLink N. Taken together, the results suggest that sLink N can increase key disc matrix molecules, namely type II collagen and aggrecan. Thus sLink N is an attractive peptide for tissue engineering and regeneration of the disc due to its anabolic effects. Finally, we show the feasibility of using the long-term whole organ culture system with adjacent intact vertebrae for studying the DG and regeneration of the IVD.

The cartilaginous endplates (CEPs) are thin layers of hyaline cartilage found adjacent to intervertebral discs (IVDs). In addition to providing structural support, CEPs regulate nutrient and metabolic exchange in the disc. In IVD pathogenesis, CEP undergoes degeneration and calcification, compromising nutrient availability and disc cell metabolism. The mechanism(s) underlying the biochemical changes of CEP in disc degeneration are currently unknown. Since calcification is often observed in later stages of IVD degeneration, we hypothesised that elevations in free calcium (Ca2+) impair CEP homeostasis. Indeed, our results demonstrated that the Ca2+ content was consistently higher in human CEP tissue with grade of disc degeneration. Increasing the levels of Ca2+ resulted in decreases in the secretion and accumulation of collagens type I, II and proteoglycan in cultured human CEP cells. Ca2+ exerted its effects on CEP matrix protein synthesis through activation of the extracellular calcium-sensing receptor (CaSR); however, aggrecan content was also affected independent of CaSR activation as increases in Ca2+ directly enhanced the activity of aggrecanases. Finally, supplementing Ca2+ in our IVD organ cultures was sufficient to induce degeneration and increase the mineralisation of CEP, and decrease the diffusion of glucose into the disc. Thus, any attempt to induce anabolic repair of the disc without addressing Ca2+ may be impaired, as the increased metabolic demand of IVD cells would be compromised by decreases in the permeability of the CEP.

Background: Isolated cerebral aspergillosis (ICA) traditionally has been associated with immunocompromised patients with dismal outcomes. Cases of ICA in immunocompetent patients are very rare and poorly described. We describe our experience of 5 immunocompetent patients with ICA and compare our experience with the literature., Methods: During the period 1996-2011, ICA was diagnosed in 5 otherwise healthy, immunocompetent patients at our institution. Medical records of the patients were reviewed with standardized data collection, including demographics, clinical presentation, radiologic features, histopathology results, treatment, and outcome., Results: All 5 patients had radiologic evidence of cerebral disease, purely parenchymal in 4 patients and dural-based in 1 patient. Radiology showed the paranasal sinuses and lungs to be clear in all patients. All patients underwent resection with antifungal therapy. All patients were female with a mean age of 23 years (range, 13-36 years). Headache (n = 5) and seizures (n = 4) were the primary presenting manifestations. Brain magnetic resonance imaging was performed in 5 patients preoperatively, and computed tomography was performed preoperatively in 4 patients. The diagnosis was made by histopathology (n = 5) and fungal cultures (n = 3) of the excised mass. Surgical resection was performed in all patients followed by treatment with amphotericin B for 2-4 weeks then oral voriconazole for 6 months. Overall mortality was 20% (n = 1). Average follow-up period was 32 months (range, 12-51 months) with interval brain magnetic resonance imaging to document eradication., Conclusions: ICA in otherwise healthy immunocompetent hosts seems to have a more favorable prognosis than what is reported for immunocompromised hosts., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Primary central nervous lymphoma (PCNSL) is a rare variant of extranodal non-Hodgkin's lymphoma with a especially poor prognosis. The diagnosis is usually encountered in immunodeficient patients but is also encountered, albeit uncommonly, in the immunocompetent. We present a 50-year-old male who developed signs and symptoms of increased intracranial pressure. Imaging revealed the presence of a fourth ventricle mass with obstructive hydrocephalus. First, the patient underwent emergency endoscopic third ventriculostomy followed, few days later, by complete tumor resection via a posterior fossa craniotomy. Postoperative histopathology revealed the lesion to be a PCNSL. He received adjuvant chemotherapy and radiation and remained with no recurrence on regular imaging studies for 18-month followup. We report herein the fourth case of isolated PCNSL lesion to the fourth ventricle in the literature and provide the rationale for our belief that craniotomy and tumor resection, if feasible, should be the initial line of management in similar cases to relieve hydrocephalus and achieve the diagnosis.

Introduction: Cerebellar hemorrhage remote from the operative site is an unpredictable and rare complication in neurosurgery, with reported rates of morbidity and mortality in the literature of 8.4% and 7.8%, respectively. The range of procedures associated with remote cerebellar hemorrhage is diverse and includes both supratentorial and spinal procedures that entail significant cerebral spinal fluid loss or resection of supratentorial content. We present here the first documented case of remote cerebellar hemorrhage after controlled supratentorial cerebral spinal fluid drainage by ventriculoperitoneal shunt, and discuss the proposed pathophysiology and treatment., Case Presentation: We present the case of a four-month-old Saudi Arabian male baby who presented with progressive symptoms and signs of congenital hydrocephalus. An uneventful ventriculoperitoneal shunting was performed with our patient recovering smoothly in the immediate postoperative period. On the next day, he had frequent episodes of vomiting and became lethargic. An urgent computed tomography scan of his brain revealed mild ventricular decompression and unexpected cerebellar hemorrhage. The infant was put under close observation, with marked spontaneous improvement over 48 hours and complete resolution of the hemorrhage on a follow-up computed tomography brain scan two weeks later. On regular outpatient visits at one, three and twelve months, he had no neurological deficit., Conclusion: Remote cerebellar hemorrhage is a complication that remains enigmatic in terms of both the underlying mechanism and clinical behavior. Our case revealed that the risk factors identified in the literature are not sufficient in predicting patients at risk of developing remote cerebellar hemorrhage. Our report also adds to the growing body of evidence challenging the currently accepted hypothesis explaining the pathomechanism of remote cerebellar hemorrhage. It thereby remains an unpredictable hazard that requires further study and increased awareness, as many cases in the literature are incidental findings.

Myelopathy at the level of the atlas is rarely encountered by the practicing spine surgeon. Due to the region's unique anatomy, compression of the cord at this level is either caused by a large compressing lesion or an abnormally stenotic canal. We describe a rare instance of a congenitally stenotic canal due to a hypoplastic intact posterior arch of atlas, coexisting with an extremely rare ossified transverse ligament of the atlas. The coexistence of these two lesions has only been documented thrice before. We describe the clinical presentation, imaging findings, and favorable response to surgery.

Background: The clinical significance of post-extubation swallowing dysfunction (PSD) is profound, resulting in both increased morbidity and mortality. Specific risk factors have not been described in an injured patient cohort. The purpose of this pilot study was to elucidate independent factors that predict PSD in this population., Methods: A retrospective cohort analysis was performed on 150 consecutive trauma patients intubated for more than 48 hours. Assessment of swallowing function after extubation was performed by a simple bedside speech pathology evaluation. Patients then were divided into 2 groups: those with and those without PSD. Backwards stepwise logistic regression analysis then was used to determine independent predictors of PSD after controlling for important injury characteristics and patient demographics., Results: The incidence of PSD in our study cohort was 41%. Patients with PSD, although older than non-PSD patients (48 vs 37.5 y; P = .001), were similar with respect to admission Glasgow coma score (GCS) and injury severity score. Regression analysis revealed that age older than 55 years (odds ratio, 2.60; P = .037; 95% confidence interval, 1.1-6.4) and ventilator days (odds ratio, 1.14; P = .001; 95% confidence interval, 1.1-1.2) were significant independent risk factors for PSD. Interpretation of these odds ratios revealed that those patients older than age 55 had more than a 2.5-fold greater risk of PSD. The risk increased by 14% for every day a patient required intubation. There was no significant association between PSD and injury severity score, GCS, presence of medical comorbidities, or development of nosocomial pneumonia., Conclusions: PSD is a common occurrence in trauma patients. Age older than 55 years and ventilator days are independent risk factors for PSD. Injury severity, altered GCS upon arrival, comorbidities, and nosocomial pneumonia were not independent risk factors for PSD in our cohort. These results suggest that older patients with extended intensive care unit stays and ventilator requirements may benefit from early swallowing evaluation., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Assuring quality surgical trainees within the confines of reduced work hours mandates reassessment of educational paradigms. Surgical simulators have been shown to be effective in teaching surgical residents, but their use is limited by cost and time constraints. The Nintendo Wii gaming console is inexpensive and allows natural hand movements similar to those performed in laparoscopy to guide game play. We hypothesize that surgical skills can be improved through take-home simulators adapted from affordable off-the-shelf gaming consoles. A total of 21 surgical residents participated in a prospective, controlled study. An experimental group of 14 surgical residents was assigned to play Marble Mania on the Nintendo Wii using a unique physical controller that interfaces with the WiiMote controller followed by a simulated electrocautery task. Seven residents assigned to the control group performed the electrocautery task without playing the game first. When compared with the control group, the experimental group performed the task with fewer errors and superior movement proficiency (P < 0.05). The experimental group demonstrated increased ambidexterity with improvement in proficiency of the nondominant hand over time. In conclusion, the Nintendo Wii gaming device along with Marble Mania serves as an effective take-home surgical simulator.

A case is presented of a 65-year-old male who presented with an acute anterior wall myocardial infarction. An initial coronary angiogram demonstrated an ulcerated atherosclerotic plaque in the left main coronary artery. After 48 h of aggressive medical therapy including a 2b3a glycoprotein blocking agent, repeat angiography demonstrated resolution of the ulcerated plaque. The process of atherosclerotic plaque rupture is of dynamic nature., (Copyright 2007 S. Karger AG, Basel.)

The term postpartum psychosis refers to a group of severe and heterogeneous disorders with psychotic symptoms that occur most frequently in the context of a mood disorder during the postpartum period. We report a case of 'postpartum psychosis' possibly associated with postpartum thyroiditis in a 29 year-old woman. The appearance of psychotic symptoms was chronologically related to the onset of postpartum thyroiditis and resolution of psychosis synchronized with the achievement of biochemical euthyroidism. The patient had typical symptoms of 'classic postpartum psychosis' (a historical term not included in DSM-IV, but used frequently by many physicians to describe diagnostic and therapeutic challenges posed by puerperal psychoses). Three months postpartum, the patient began to believe that she was pregnant with the Christ child, although she was not pregnant. Her delusions resolved around the 'pregnancy' and harm to her 'unborn' child. She also believed that her child (Jesus) was going to be killed. Other key symptoms included hallucinations, mixed mood symptoms, agitation and transient disorientation. Her DSM-IV diagnosis on admission was major depression with psychotic features and her discharge diagnosis (most likely diagnosis) was psychotic disorder due to thyrotoxicosis caused by postpartum thyroiditis. The differential diagnosis of co-occurring psychosis and postpartum thyroiditis can be examined relative to four possibilities: (1) psychosis due to thyrotoxicosis caused by postpartum thyroiditis; (2) a coincidence (no association between psychosis and postpartum thyroiditis); (3) precipitation of psychotic symptoms and disorientation related to a postpartum thyroiditis in a woman with a pre-existing mood disorder; or (4) both psychosis and thyroiditis caused by a pre-existing defect in autoimmunity. The authors stress the importance of early diagnosis and prompt treatment of postpartum psychosis. They discuss the indications for thyroid screening in postpartum psychoses. Further research is needed to clarify the nosology and mechanisms of severe postpartum disorders and to elucidate treatment-relevant and etiologically-distinct subsets of postpartum psychosis.

Tryptase, a neutral protease of human mast cells, is a potentially important indicator of mast cell involvement in various clinical conditions. The current study examined the time course of appearance and disappearance of tryptase in the circulation after an anaphylactic event and the stability of both endogenous and exogenous tryptase in terms of freeze-thawing and temperature. The peak level of tryptase after an experimentally induced systemic anaphylactic reaction occurred 1-2 h after the initiating bee sting in each of three subjects, in contrast to histamine levels which peaked at 5-10 min. In some cases elevated levels of tryptase may not be detected during the initial 15-30 min. Tryptase levels then declined under apparent first order kinetics with a t1/2 of approximately 2h. Similar disappearance kinetics were observed for two subjects presenting in the emergency room with immediate type reactions, one with severe asthma after indomethacin ingestion, the other with systemic anaphylaxis after a bee sting. Histamine levels declined rapidly and were back to baseline by 15-60 min. Measured levels of tryptase in serum or plasma were not diminished by up to four freeze-thaw cycles. Incubation of serum samples taken from subjects with elevated levels of tryptase at 22 and 37 degrees C indicated that greater than 50% of endogenous tryptase was still detected after 4 d. Purified tryptase added to serum or plasma and incubated as above was less stable: approximately 50% of exogenous tryptase in serum and approximately 15% in plasma was detected after 2d of incubation. Therefore, optimally samples should be stored frozen, but even those stored at room temperature for up to 4 d should be satisfactory. The best time to obtain samples for tryptase determinations is 1-2 h after the precipitating event, but depending on the magnitude of the initial response elevated levels of tryptase may be present in the circulation for several hours.