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Gas diffusion electrodes are essential components of common fuel and electrolysis cells but are typically made from graphitic carbon or metallic materials, which do not allow light transmittance and thus limit the development of gas-phase based photoelectrochemical devices. Herein, the simple and scalable preparation of F-doped SnO 2 (FTO) coated SiO 2 interconnected fiber felt substrates is reported. Using 2-5 µm diameter fibers at a loading of 4 mg cm -2 , the resulting substrates have porosity of 90%, roughness factor of 15.8, and Young's Modulus of 0.2 GPa. A 100 nm conformal coating of FTO via atmospheric chemical vapor deposition gives sheet resistivity of 20 ± 3 Ω sq -1 and loss of incident light of 41% at illumination wavelength of 550 nm. The coating of various semiconductors on the substrates is established including Fe 2 O 3 (chemical bath deposition), CuSCN and Cu 2 O (electrodeposition), and conjugated polymers (dip coating), and liquid-phase photoelectrochemical performance commensurate with flat FTO substrates is confirmed. Finally, gas phase H 2 production is demonstrated with a polymer semiconductor photocathode membrane assembly at 1-Sun photocurrent density on the order of 1 mA cm -2 and Faradaic efficiency of 40%., (© 2023 The Authors. Advanced Materials published by Wiley-VCH GmbH.)

Causalgia, officially known as complex regional pain syndrome type II, is a pain syndrome characterized by severe burning pain, motor and sensory dysfunction, and changes in skin color and temperature sensation distal to an injured peripheral nerve. The pain syndrome primarily tends to affect combat soldiers after they sustain wartime injuries from blasts and gunshots. Here, the authors provide a historical narrative that showcases the critical contributions of military physicians to our understanding of causalgia and to the field of peripheral nerve neurosurgery as a whole.

Introduction: Evidence-based, clinical practice guidelines in the management of central nervous system tumors (CNS) continue to be developed and updated through the work of the Joint Section on Tumors of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS)., Methods: The guidelines are created using the most current and clinically relevant evidence using systematic methodologies, which classify available data and provide recommendations for clinical practice., Conclusion: This update summarizes the Tumor Section Guidelines developed over the last five years for non-functioning pituitary adenomas, low grade gliomas, vestibular schwannomas, and metastatic brain tumors.

Objective: Spinal cord injury (SCI) is an area of key interest in military medicine but has not been studied among the US Army Special Forces (SF), the most elite group of US soldiers. SF soldiers make up a disproportionate 60% of all Special Operations casualties. The objective of this study was to better understand SCI incidence in the SF, its mechanisms of acquisition, and potential areas for intervention by addressing key issues pertaining to protective equipment and body armor use., Methods: An electronic survey questionnaire was formulated with the close collaboration of US board-certified neurosurgeons from the Mount Sinai Hospital and Cleveland Clinic Departments of Neurosurgery, retired military personnel of the SF, and operational staff of the Green Beret Foundation. The survey was sent to approximately 6000 SF soldiers to understand SCI diagnosis and its associations with various health and military variables., Results: The response rate was 8.2%. Among the 492 respondents, 94 (19.1%) self-reported an SCI diagnosis. An airborne operation was the most commonly attributed cause (54.8%). Moreover, 87.1% of SF soldiers reported wearing headgear at the time of injury, but only 36.6% reported wearing body armor, even though body armor use has significantly increased in post-9/11 SF soldiers compared with that in their pre-9/11 counterparts. SCI was significantly associated with traumatic brain injury, arthritis, low sperm count, low testosterone, erectile dysfunction, tinnitus, hyperacusis, sleep apnea, posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. Only 16.5% of SF soldiers diagnosed with SCI had been rescued via medical evacuation (medevac) for treatment., Conclusions: A high number of SF soldiers self-reported an SCI diagnosis. Airborne operations landings were the leading cause of SCI, which coincided with warfare tactics employed during the Persian Gulf War, Operation Iraqi Freedom, and other conflicts. A majority of SCIs occurred while wearing headgear and no body armor, suggesting the need for improvements in protective equipment use and design. The low rate of medevac rescue for these injuries may suggest that medical rescue was not attainable at the time or that certain SCIs were deemed minor at the time of injury.

Purpose: Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients., Methods: Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle., Results: Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications., (© 2020 Wiley Periodicals, Inc.)

The challenges of neurosurgical patient management and surgical decision-making during the 2019-2020 COVID-19 worldwide pandemic are immense and never-before-seen in our generation of neurosurgeons. In this case-based formatted report, we present the Mount Sinai Hospital (New York, NY) Department of Neurosurgery institutional experience in the epicenter of the pandemic and the guiding principles for our current management of intracranial, skull base, and spine tumors. The detailed explanations of our surgical reasoning for each tumor case is tailored to assist neurosurgeons across the United States as they face these complex operative decisions put forth by the realities of the pandemic.

Objective Neurosurgeons have taken on the role of innovators, continuing to move the field forward over the centuries. More recently, innovation has taken the form of new technological devices and therapeutics, which require patenting. The aim of this study is to identify major areas of innovation in the field of neurosurgery by evaluating patent records. Methods This study quantifies the number of patents the American Association of Neurological Surgeons (AANS) neurosurgeons hold across different subspecialties. The United States Patent and Trademark Office (USPTO) patent database was queried using the names of 7,293 AANS members who filed patents between 1976 and 2019. Results A total of 346 (4.7%) AANS neurosurgeons hold a total of 1,025 patents. The number of patents held by each neurosurgeon ranged from one to 109. The areas that patents were filed under include cellular and genetic science (40), drug delivery (45), image guidance (82), neuromodulation (52), pain (7), peripheral nerve stimulation (24), spine (398), surgical devices (148), trauma (16), tumor (78), vascular (67), and other (68). No patents were filed under pediatrics (0). The fields with the greatest number of filed patents are spine, instruments/devices, and image guidance. Conclusion Given the technical nature of the field of neurosurgery, instruments and devices that improve localization, visualization, targeting, and spinal reconstruction are often in demand. Furthermore, since the rates of spinal procedures and implants continue to increase, higher patenting may be motivated by the opportunity to develop new products that can result in royalty payments to neurosurgeons. The advent of new technologies undoubtedly continues to push the field of neurosurgery forward., Competing Interests: John Adler is the Founder and CEO of both Cureus.com and Zap Surgical and named inventor on more than 20 patents, some of which are included in this publication (i.e., Gamma Knife, Cyberknife). Nicholas Boulis has patented the use of a stimulus to white matter. Constantinos Hadjipanayis owns patents on the use of nanoparticles for targeted therapy.. John A. Adler, founder of Cureus Inc., contributed to our work by providing direction and overview., (Copyright © 2020, Baron et al.)

Background: Shoulder pseudodislocation, or "drooping shoulder," presents with acute pain and deformity of the joint, with radiographs demonstrating inferior subluxation of the humeral head relative to the glenoid fossa. The diagnosis must be made promptly and distinguished from true glenohumeral dislocation, both to avoid unnecessary attempts at closed reduction and to facilitate investigation of the underlying cause, which may include septic arthritis, hemarthrosis, or other emergent etiologies. Point-of-care ultrasound (POCUS) may be useful in the evaluation of emergency department (ED) patients with suspected pseudodislocation., Case Report: A 50-year old female presented to the ED with an acutely painful and deformed shoulder but atypical history and physical examination. Initial radiography appeared to show a glenohumeral dislocation, but POCUS, done to guide intra-articular lidocaine injection, led to recognition of pseudodislocation and subsequent diagnosis of calcific tendinitis/bursitis, a condition not previously associated with inferior humeral subluxation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Shoulder pseudodislocation must be considered in the evaluation of patients with suspected glenohumeral dislocation, but atypical features on history, physical examination, or initial plain radiography. POCUS may facilitate prompt diagnosis and identification of the underlying etiology., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Socioeconomic topics such as federal mandates/regulations, conflict of interest, and practice management have become increasingly important for all neurosurgeons. Graduating residents immediately need a host of skills to successfully navigate neurosurgical practice. Surgical and medical skills are closely evaluated through the American Board of Neurological Surgery, and a formal socioeconomic curriculum has been developed with defined milestones. Nevertheless, little has been done to evaluate neurosurgery resident competence in socioeconomic and medicolegal principles. The purpose of this study was to assess the competence of Accreditation Council for Graduate Medical Education neurosurgical residents in socioeconomic knowledge., Methods: Neurosurgery resident members of the American Association of Neurological Surgeons (N = 1385) were sent a Survey Monkey of 10 questions. The survey covered the most basic of socioeconomic principles. Initial survey responses were collected across a 1-month period from April to May 2018., Results: The response rate was 14% (194/1385). Overall, neurosurgery residents would have received a grade of D, with an average score of 67% on the survey. For 7 of the 10 questions, the majority (>50%) of neurosurgery residents answered correctly. Furthermore, for 3 questions, more than 90% of residents selected the correct answer. However, for one-half of all questions, residents averaged a score of less than 65%. Residents tended to answer questions correctly for physician compensation and compensation models, but incorrectly for topics of informed consent, Controlled Substances Act, and conflicts of interest., Conclusion: With the increasing complexity of neurosurgery practice, solid knowledge of socioeconomic topics is essential. The study confirms suspected deficiencies in socioeconomic proficiency among neurosurgery residents, despite the availability of a validated curriculum. This knowledge gap will likely affect career success and satisfaction. Nevertheless, this survey had a significantly low response rate, and it may be an incomplete representation of the neurosurgical resident mind. Focused educational initiatives through the neurosurgical Residency Review Committee and individual training programs must facilitate an action plan that ensures the effective implementation of socioeconomic curricula., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Surgical management strategies for glioblastoma (GBM) may differ among neurosurgeons with initial biopsy of suspected tumors and the need for early re-resection of tumors within 30 days of initial surgery. This study was initiated by the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) Tumor Section's interest in understanding the rates at which pre- and post-resection procedures, specifically biopsies prior to definitive resection and early re-resections, are performed by U.S. neurosurgeons in the management of GBM., Methods: A ten-question survey was distributed to members of the AANS/CNS Tumor Section., Results: The survey response rate among AANS/CNS Tumor Section surgeons was approximately 16%. Results showed that a majority of respondents performed surgery on 11-25 GBM cases annually. Of those cases, most neurosurgeons claimed that biopsies are rarely performed prior to tumor resection, but in the < 10% of cases for which biopsies are done, common reasons are to confirm radiological findings or improve the treatment plan. Likewise, re-resections are rare, but in the < 5 cases most neurosurgeons performed annually, common reasons included incomplete initial resections, referrals for greater resection, or unspecified reasons., Conclusions: Further studies are needed to confirm the results of this study, which shows low rates of stereotactic and open biopsy and early re-resection procedures performed among neurosurgeons. These rates may help form guidelines in the treatment of GBM and encourage the use of surgical adjuncts that increase the extent of resection of these tumors, thereby reducing rates of early recurrence.

Objective: Atypical (World Health Organization grade II) meningiomas (AMs) have been associated with a substantial risk of recurrence even after complete, gross total resection (GTR). The present study evaluated the clinical and AM tumor histopathological features that might predict for the risk of recurrence and survival within this patient population., Methods: The data from 72 consecutive patients who had undergone primary GTR for AM from 2007 to 2016 and corresponding tumor specimens at a single institution were reviewed. The preoperative patient and tumor characteristics were correlated with the postresection outcomes, including recurrence and 1-year survival. Cox regression models on recurrence-free survival (RFS) and Kaplan-Meier survival estimates were performed., Results: The overall 1-, 3-, and 5-year RFS estimates for the AM cohort were 100.0%, 82.4%, and 78.1% after resection, respectively. A high mitotic index was an independent predictor of RFS on Cox regression analysis (hazard ratio, 1.26; P = 0.008), and the tumor volume showed a trend toward a significant association (hazard ratio, 0.93; P = 0.079). Patient age and the mitotic index were significantly associated with 1-year mortality (odds ratio, 1.11 and 1.36, respectively; P = 0.028 and P = 0.045, respectively)., Conclusions: AM tumors with a high proliferative index showed an increased likelihood of recurrence and short-term survival even after complete GTR. A smaller tumor volume might also have contributed to an increased risk of recurrence for patients with AM. Although other histopathological features were not linked to recurrence or mortality for patients with AM, the biopsy findings can indicate key predictive information, and further molecular analysis might reveal additional prognostic markers., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: One of the most frequent complications after endoscopic endonasal approach (EEA) for resection of pituitary tumors is cerebrospinal fluid (CSF) leaks. With the introduction of the pedicled nasoseptal flap, the reconstruction of the skull base has improved significantly resulting in a decrease in the occurrence of persistent CSF leaks. We present our experience utilizing the pedicled nasoseptal flap technique after EEA for reconstruction of the skull base in cases where CSF leak was detected., Methods: Data for patients undergoing EEA for pituitary tumors was retrospectively reviewed. These included demographic, clinical, operative, radiographic, and pathological information. Incidence of post-operative complications and CSF leaks were recorded. Descriptive statistical analysis was performed., Results: Between 2008 and 2015, 67 patients and 69 hospital admissions with pituitary tumors underwent a nasoseptal flap to reconstruct a skull base defect at Johns Hopkins Hospital. The mean age at surgery was 54.5±14.2 years. Fifty-two percent of patients were male. Forty-six percent of patients were white, 33% African-American, and 12% belonged to other racial groups. There was an intraoperative CSF leak in 39% of patients. Seventy percent of patients with an intraoperative CSF leak had a nasoseptal flap reconstruction of the skull base. There were zero postoperative CSF leaks., Conclusion: With the introduction of the pedicled nasoseptal flap for reconstruction of the skull base after EEA for resection of pituitary adenomas, the incidence of postoperative CSF leaks has decreased significantly. In this retrospective analysis, we demonstrate the effectiveness of the use of nasoseptal flap in repairing CSF leak after EEA., Competing Interests: The authors have no financial conflicts of interest., (Copyright © 2019 The Korean Brain Tumor Society, The Korean Society for Neuro-Oncology, and The Korean Society for Pediatric Neuro-Oncology.)

Background: Medical malpractice litigation is an issue of major concern in neurosurgery, with 19.1% of neurosurgeons facing a claim annually. Neurosurgery possesses the greatest risk of malpractice of any specialty, likely owing to the complex clinical environment and disease severity. In the present study, we have characterized such litigation to determine the common factors that compel plaintiffs to file these claims., Methods: WestLawNext, a prominent legal database, was used to identify all cases from 1985 to 2016 related to brain tumors. A total of 225 cases were identified, and each was analyzed for the cause of litigation (multiple causes were permitted). Because many had >1 ground for litigation, the reported percentages were based on the total counts of litigation rather than the number of cases. Additional information was collected from each case, including location, tumor type, and physician specialty., Results: The cases were distributed across 36 states and U.S. territories: California (n = 42; 20%) and New York (n = 28; 13%) had the greatest number of cases. The top reasons for litigation were failure to diagnose (n = 109; 28%), failure to treat (n = 72; 18%), procedural error (n = 63; 16%), and failure to refer for diagnostic tests (n = 55; 14%). The most common diagnoses included pituitary adenoma (n = 26; 12%), acoustic neuroma (n = 27; 12%), and meningioma (n = 23; 10%)., Conclusions: Malpractice litigation contributes to high overhead and physician burnout and escalates the cost of patient care. We found that benign brain tumors were the most common in litigation and that surgical issues accounted for only a small percentage., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: We sought to compare timing of intervention for patients with spinal cord injury (SCI) requiring surgical procedures during weekend versus weekday admissions., Methods: The National Inpatient Sample database from 2012 to 2014 was queried to identify patients with SCI who underwent surgical treatment (decompression with or without stabilization) as an emergent/urgent procedure. Timing of intervention, inpatient morbidity, and inpatient mortality were compared between patients admitted during the weekend versus a weekday. Multiple logistic regression analyses were also performed., Results: A total of 9390 patients were identified (mean age 55 years, 73.2% male) from the database, with 34.1% admitted during the weekend and 65.9% during a weekday. The average day of intervention for the entire cohort was 2.8 (SD 3.9, interquartile range 1-4); day 2.7 (standard deviation [SD] 4.0) versus day 2.8 ([SD] 3.9) for patients admitted in a weekend versus weekday (P = 0.418). After controlling for patient age, sex, and injury severity score on multiple logistic regression analysis, weekend admission was not significantly associated with early intervention (odds ratio [OR] 0.99; 95% confidence interval [CI], 0.82-1.21; P = 0.993), complication occurrence (OR 1.09; 95% CI, 0.86-1.38; P = 0.476), or inpatient mortality (OR 0.83; 95% CI, 0.44-1.56; P = 0.563). Patients with complete/American Spinal Injury Association A injuries were more likely to undergo early intervention (OR 2.09; 95% CI, 1.31-3.31; P = 0.002)., Conclusion: In this national study, patients with SCI who were admitted during the weekend received surgical intervention as early as patients admitted during a weekday. Furthermore, no differences in complication or mortality rates between groups were found., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Thoracic vertebral fracture repair after a traumatic injury can be associated with significant risk for postoperative complications. Surgical outcomes are further complicated by patient comorbidity, particularly diabetes mellitus. This study compared outcomes and complication rates for traumatic thoracic vertebral fracture repair in a matched sample of patients with diabetes and nondiabetic control subjects., Methods: Patients with a surgical repair of a trauma-induced thoracic vertebral fracture treated from 2010 to 2015 were identified from the Trauma Quality Improvement Program database, yielding 5557 cases. Patients with comorbid diabetes were matched by propensity score matching (PSM) with patients without diabetes on age, race, and body type and were compared by postoperative complications and clinical outcomes., Results: Prior to PSM, the diabetes group was older on average and had a greater proportion of patients who were obese (Ps < 0.001). After PSM, each group consisted of 544 patients (N = 1088) and no longer differed by any baseline characteristic. Comorbid diabetes was associated with longer average length of hospital stay and greater frequency of several major and minor postoperative complications (Ps < 0.05), including prolonged intensive care, pneumonia, acute renal failure, stroke, pressure ulcers, and urinary tract infections, but no differences were found in reoperation rates or in-hospital mortality., Conclusions: Diabetes comorbidity can significantly increase the risk of postoperative complications after traumatic thoracic vertebral fracture repair, which may lead to delayed recovery and greater health care-related costs. This finding is an important consideration for surgical decision-making and patient counseling on treatment options with this comorbid condition., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: It is well-documented that geriatric patients are at risk for serious injuries after fracture due to pre-existing medical conditions, physical changes of aging, and medication effects. Frailty has been demonstrated to be a predictor of morbidity and mortality in inpatient head and neck surgery, and for surgical intervention for adult spinal deformity and degenerative spine disease. However, the impact of frailty on complications following thoracolumbar/thoracic fractures are unknown and has not been previously assessed in the literature, particularly in a nationwide setting., Patients and Methods: This was a retrospective study of the prospectively-collected American College of Surgeons National Surgical Quality Improvement database for the years 2007 through 2012. Patients who underwent spinal decompression (+/- fusion) or an alternative intervention, defined as vertebroplasty or kyphoplasty (VP/KP) for thoracic or thoracolumbar fracture were identified. Frailty status was determined using a modified frailty index from the Canadian Study of Health and Aging Frailty Index, with frailty defined as a score = 0.27. 30-day morbidity and mortality were compared between frail and non-frail patients in each treatment group., Results: A total of 303 patients were included in this study. Of these, 38% of patients had VP/KP and 62% underwent surgery. Within the VP/KP cohort, 26% were frail. The proportion of these patients who developed at least one complication was 3.3% versus 3.6% for non-frail patients (p = 1.0). The 30-day mortality for frail versus not frail patients in this cohort was 0% versus 2.4% (p = 1.0). Among the surgical group, 13% were frail. In contrast, the likelihood of complications was 33.3% among frail patients and 4.2% for non-frail patients (p < 0.001). Frail patients also had a 16.7% 30-day mortality rate as compared to 0.6% in the non-frail group (p = 0.001). When comparing the frail versus non-frail patients overall, frail patients had a complication rate of 16.7%, as opposed to 4.0% in non-frail patients., Conclusion: Frailty and surgical intervention are correlated with a higher 30-day complication rate in patients with thoracic and thoracolumbar fracture. This finding is an important consideration for surgical decision-making and patient counseling on treatment options., (Copyright © 2018 Elsevier B.V. All rights reserved.)

OBJECTIVE With increasing general use of antidepressants (ADs), multiple studies have noted a small protective effect of ADs for patients with glioma, but their impact on meningioma has not been established. This study aims to evaluate the role of ADs in the context of additional clinical factors in relation to long-term risk of meningioma recurrence. METHODS One hundred five patients with an intracranial meningioma presenting from 2011-2014 with at least 3 years of follow-up (median 4.2 years) after resection were reviewed. AD use along with demographics, tumor characteristics, and outcomes were recorded. Multivariate logistic regression was used to analyze the association of AD use with tumor recurrence, including other clinical measures significantly associated with recurrence as covariates. RESULTS Twenty-nine patients (27.4%) were taking ADs (27 selective serotonin reuptake inhibitors, 2 norepinephrine-dopamine reuptake inhibitors) prior to tumor recurrence. Their tumors largely affected the frontal (31.0%) or parietal lobe (17.2%) and were located in convexity, parasagittal, or falcine (CPF) areas more frequently than skull base areas relative to the tumors of non-AD users (p = 0.035). AD use was found to be an independent predictor of recurrence, in addition to subtotal resection and WHO grade II/III classification (p values < 0.05). The median time from AD prescription to tumor recurrence was 36.6 months (interquartile range [IQR] = 20.9-62.9 months) and median length of AD use was 41.4 months (IQR = 24.7-62.8 months). CONCLUSIONS AD use was an independent predictor of meningioma recurrence. This association may be due to mood or affective changes caused by tumor location in CPF regions that may be a sign of early recurrence. The finding calls attention to AD use in the management of patients with meningioma, and warrants further exploration of an underlying relationship.

Background: Benign meningiomas constitute 80%-90% of all meningiomas and represent the most common type of central nervous system tumor in adults. The vast majority of meningiomas are minimally symptomatic or asymptomatic early in their onset and thereby can often result in delayed diagnosis. Early diagnosis of meningioma is critical, as it can maximize treatment options and improve outcomes and survival. Although seizures and focal neurologic deficits are considered to be the most prevalent symptoms, depression also may be an important and significant sign. A subtle neurologic depression may be an even early presenting sign of meningioma and may precede more traditional presenting symptoms., Methods: We performed a comprehensive literature review that analyzes the results of prospective studies and case reports on this topic., Results: Our findings show evidence to suggest that depression may be correlated with meningioma presentation. Its prevalence is possibly increased with an anterior location of the tumor., Conclusions: For patients who exhibit nuances of depression without a history of psychiatric illness, an index of suspicion for meningioma may be warranted., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Superficial siderosis is a rare, neurodegenerative disease caused by toxic accumulation of hemosiderin on the surface of the brain and the spinal cord, most commonly from chronic subarachnoid hemorrhage., Aims: The aim of this study was to assess the clinical and radiological outcomes of superficial siderosis patients using deferiprone, a cell permeant iron chelator. Subjects obtained pre- and post-treatment brain MRIs and weekly laboratory tests. Osirix software was used to develop a method of quantifying hemosiderin deposition. Three-dimensional whole brain images of gradient echo images were rendered and compared by dividing the mean T2 hyperintensity to the maximal cerebrospinal fluid signal., Results: A total of 38 subjects completed the study, of which clinical and radiological data were available for 30. The average age was 64 years (range 37-86), 53% were male, 94% were white. Nineteen subjects (63%) reported either no progression of disease or an improvement in at least one neurological domain, with 40% of patients reporting a stabilization in hearing function and 30% reporting stable or improved coordination and walking. By MRI, there was an overall mean increase in T2 hyperintensity of the whole brain of 1%-13% over the 2-year time period in half of patients, indicating a reduction hemosiderosis. There were no cases of agranulocytosis, and declines of white blood cells counts and neutrophils averaged <10%. Fatigue was the most common side effect., Conclusion: This is the first long-term prospective study of superficial siderosis on the iron chelator, deferiprone. MRI quantification of hemosiderin appears to demonstrate a measurable reduction in half of patients and this correlated with a stabilized or improving disease course. A future placebo-controlled trial is necessary to determine whether deferiprone is an effective therapy for superficial siderosis., (© 2017 John Wiley & Sons Ltd.)

Objective: To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource-limited setting., Methods: Approximately half of the emergency medicine resident physicians at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, were trained in a CPUS protocol. Adult patients triaged to the resuscitation area of the emergency department (ED) were enrolled if they exhibited signs or symptoms of shock or respiratory distress. Patients were assigned to the intervention group if their treating physician had completed the CPUS training. The physician's initial diagnostic impression was recorded immediately after the history and physical examination in the control group, and after an added CPUS examination in the intervention group. This was compared to a standardised final diagnosis derived from post hoc chart review of the patient's care at 24 h by two blinded, independent reviewers using a clearly defined and systematic process. Secondary outcomes were 24-h mortality and use of IV fluids, diuretics, vasopressors and bronchodilators., Results: Of 890 patients presenting during the study period, 502 were assessed for eligibility, and 180 patients were enrolled. Diagnostic accuracy was higher for patients who received the CPUS examination (71.9% vs. 57.1%, Δ 14.8% [CI 0.5%, 28.4%]). This effect was particularly pronounced for patients with a 'cardiac' diagnosis, such as cardiogenic shock, congestive heart failure or acute valvular disease (94.7% vs. 40.0%, Δ 54.7% [CI 8.9%, 86.4%]). Secondary outcomes were not different between groups., Conclusions: In an urban ED in Ghana, a CPUS examination improved the accuracy of the treating physician's initial diagnostic impression. There were no differences in 24-h mortality and a number of patient care interventions., (© 2017 John Wiley & Sons Ltd.)

Background: Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disease associated with a serological antibody to aquaporin-4 (AQP4) detectable in up to 80% of patients. The enzyme-linked immunosorbent assay (ELISA) is one of the most popular methods of testing for anti-AQP4 antibodies that results with a titer in which < 3 Units/ml is negative, 3-5 is borderline and 5+ is positive. The value of the positive titer in predicting long term disease course is currently unknown., Methods: This is a retrospective analysis of NMOSD patients from five centers around the world: Baltimore, USA, Philadelphia, USA, Shanghai, China, Berlin, Germany, and Medellin, Columbia, where ELISA titers on anti-AQP4 antibody testing is available. Inclusion criteria include a diagnosis of NMOSD and seropositive anti-AQP4 antibody test with titer = /> 3 Units/ml. Patients were stratified into three groups by titer: 3-30 Units/ml (low), 31-100 Units/ml (medium), and 101+ Units/ml (high). Demographic factors such as age at onset, race, and sex were collected along with clinical features such as annualized relapse rate, duration of disease, location of relapses, and treatment history., Results: A total of 139 NMOSD patients met criteria for inclusion in this study, stratified into three groups by titer: 42 subjects with low titers of 3-30 Units/ml, 30 subjects with medium titers of 31-100 Units/ml and 67 subjects with high titers of 101 or greater ELISA Units/ml. The average age at onset, sex and race distribution were not significantly different among the groups. The number of patients untreated in each group was similar (< 25%) as was the average annualized relapse rate (0.591-0.821 relapses/year). With an average of 10 years follow up, the average disability level was not different among the three titer groups (EDSS range 3.03-3.48). The distribution of lesions, as well as their preventive treatment regimens did not differ significantly., Conclusion: Beyond a positive/borderline/negative result, the titer of the anti-AQP4 antibody ELISA assay is not predictive in the disease course for patients with NMOSD. Low titer patients experience the same disease course as medium-titer and high-titer anti-AQP4 antibody patients with NMOSD., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Atypical (World Health Organization grade II) and anaplastic (World Health Organization grade III) meningiomas are rare, accounting for less than 5% of all meningiomas. Histologic grading has a significant impact on prognosis, risk of recurrence, and the need for adjuvant radiation or chemotherapy. Extracranial metastases are even more infrequent and occur in 0.1% of all cases., Methods: Retrospective chart review of 168 patients with diagnosis of WHO grade II and III meningiomas was performed. Six patients with histologically confirmed metastatic disease were identified., Results: We discuss the clinical, radiologic, and histopathologic clinical course of 6 patients with metastasis to the lung, liver, and spine from all patients with atypical or anaplastic meningioma treated at Johns Hopkins Hospital from 1993 to 2014., Conclusions: We reviewed the literature pertaining to this phenomenon and subsequently assessed the clinical benefits of adjuvant chemotherapeutic agents in patients with meningioma with metastatic disease., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To compare post-lumbar decompression and fusion complication rates and mortality for patients without preoperative hemodialysis (HD) use with and without renal dysfunction as estimated by glomerular filtration rate (GFR) and creatinine levels., Patients and Methods: Baseline and outcome data were obtained from the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for patients over the age of 18 who underwent non-emergent lumbar fusion surgery. Preoperative HD status and GFR and creatinine levels were extracted. Variables analyzed included development of at least one complication, development of a major complication, in-hospital mortality, and length of stay., Results: A total of 29,081 patients were identified. Those with severe preoperative kidney dysfunction as estimated by GFR were more likely to develop a complication (GFR=15-30ml/min/1.73m 2 ; OR, 3.82; 95% CI, 2.061-7.082; P=<0.0001 and GFR=30-45ml/min/1.73m 2 ; OR, 2.124; 95% CI, 1.506-2.996; P<0.0001). Compared to patients with normal preoperative creatinine levels (0.75-1.0mg/dL), patients with elevated creatinine were more likely to develop at least one complication., Conclusion: Patients with low estimated GFR and elevated creatinine levels were associated with higher perioperative morbidity. This increased risk should be taken into consideration when counselling this patient population., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Introduction: The objective of this study was to analyze the content and volume of literature that has been written on cultural competency in emergency medicine (EM) since its educational imperative was first described by the Institute of Medicine in 2002., Methods: We conducted a comprehensive literature search through the PubMed portal in January 2015 to identify all articles and reviews that addressed cultural competency in EM. Articles were included in the review if cultural competency was described or if its impact on healthcare disparities or curriculum development was described. Two reviewers independently investigated all relevant articles. These articles were then summarized., Results: Of the 73 abstracts identified in the initial search, only 10 met criteria for inclusion. A common theme found among these 10 articles is that cultural competency in EM is essential to reducing healthcare disparities and improving patient care. These articles were consistent in their support for cross-cultural educational advancements in the EM curriculum., Conclusion: Despite the documented importance of cultural competency education in medicine, there appears to be only 10 articles over the past 12 years regarding its development and implementation in EM. This comprehensive literature review underscores the relative dearth of publications related to cultural competency in EM. The limited number of articles found is striking when compared to the growth of EM research over the same time period and can serve as a stimulus for further research in this significant area of EM education., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

Objective: The purpose of this study was to review cases of neuromyelitis optica spectrum disorder (NMOSD) relapses and pseudorelapses to identify early features that differentiate between them at onset of symptoms., Methods: This was a retrospective analysis of 74 hospitalizations of patients with NMOSD who were admitted to the Johns Hopkins Hospital for workup and treatment of a presumed relapse. Standard workup included MRI and blood and urine testing for metabolic and infectious etiologies. The gold standard for a relapse was defined as new or worsening symptoms and a change in neurologic examination correlating with a new or enhancing MRI lesion. A pseudorelapse was a clinical exacerbation with similar symptoms and signs but the MRI was negative, and workup identified an alternative cause for the symptoms that, when treated, resulted in the improvement of neurologic symptoms. Factors considered to be early predictors of relapses vs pseudorelapses were analyzed using the Fisher test., Results: Among 74 NMOSD hospitalizations for presumed relapse, 57 were confirmed relapses while 17 had a negative MRI and an identifiable cause of pseudorelapse. The most common causes of pseudorelapse were infection, pain, and dysautonomia. The only early predictor that reliably differentiated relapse from pseudorelapse among this NMOSD patient population was vision loss (p = 0.039). Race, sex, presentations of weakness, numbness, and bowel/bladder dysfunction, white blood cell count, and urinary tract infection were not different among patients with relapses vs pseudorelapses., Conclusions: Vision loss in NMOSD is strongly suggestive of a true relapse vs a pseudorelapse. Pseudorelapses localized to the spinal cord in patients with previous myelitis presented similarly to true relapses and could only be ruled out by a negative MRI.

Background: No licensed cholera vaccine is presently available in the United States. Cholera vaccines available in other countries require 2 spaced doses. A single-dose cholera vaccine that can rapidly protect short-notice travelers to high-risk areas and help control explosive outbreaks where logistics render 2-dose immunization regimens impractical would be a major advance.PXVX0200, based on live attenuated Vibrio cholerae O1 classical Inaba vaccine strain CVD 103-HgR, elicits seroconversion of vibriocidal antibodies (a correlate of protection) within 10 days of a single oral dose. We investigated the protection conferred by this vaccine in a human cholera challenge model., Methods: Consenting healthy adult volunteers, 18-45 years old, were randomly allocated 1:1 to receive 1 oral dose of vaccine (approximately 5 × 10(8) colony-forming units [CFU]) or placebo in double-blind fashion. Volunteers ingested approximately 1 × 10(5) CFU of wild-type V. cholerae O1 El Tor Inaba strain N16961 10 days or 3 months after vaccination and were observed on an inpatient research ward for stool output measurement and management of hydration., Results: The vaccine was well tolerated, with no difference in adverse event frequency among 95 vaccinees vs 102 placebo recipients. The primary endpoint, moderate (≥3.0 L) to severe (≥5.0 L) diarrheal purge, occurred in 39 of 66 (59.1%) placebo controls but only 2 of 35 (5.7%) vaccinees at 10 days (vaccine efficacy, 90.3%; P < .0001) and 4 of 33 (12.1%) vaccinees at 3 months (vaccine efficacy, 79.5%; P < .0001)., Conclusions: The significant vaccine efficacy documented 10 days and 3 months after 1 oral dose of PXVX0200 supports further development as a single-dose cholera vaccine., Clinical Trials Registration: NCT01895855., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.)

Opinion Statement: Neuromyelitis optica spectrum disorder (NMOSD) is a rare, autoimmune disease of the central nervous system that primarily attacks the optic nerves and spinal cord leading to blindness and paralysis. The spectrum of the disease has expanded based on the specificity of the autoimmune response to the aquaporin-4 water channel on astrocytes. With wider recognition of NMOSD, a standard of care for treatment of this condition has condition based on a growing series of retrospective and prospective studies. This review covers the present state of the field in the treatment of acute relapses, preventive approaches, and therapies for symptoms of NMOSD.

We observed an increase in the ratio of pathogenic Babesia microti to B. odocoilei in adult Ixodes scapularis ticks in Maine. Risk for babesiosis was associated with adult tick abundance, Borrelia burgdorferi infection prevalence, and Lyme disease incidence. Our findings may help track risk and increase the focus on blood supply screening.

This investigation sought to determine whether the pattern of performance differed between young and elderly normally hearing adults on a closed v. open-set discrimination task. The California Consonant Test was administered at 32 dB SL (re:SRT) to 20 young and 20 elderly normally hearing subjects under two conditions: one which required subjects to mark their response on a multiple choice answer form; and a second which required subjects to provide a one-word written response on a blank answer form. The only significant difference occurred within the young group between conditions (closed-set, open-set). The young group's speech discrimination was significantly better in the closed-set condition then in the open-set condition. No other differences were significant. The results question the concept of phonemic regression as a concomitant of ageing.