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Background and Objectives: Neurosurgeons and hospitals devote tremendous resources to improving recovery from lumbar spine surgery. Current efforts to predict surgical recovery rely on one-time patient report and health record information. However, longitudinal mobile health (mHealth) assessments integrating symptom dynamics from ecological momentary assessment (EMA) and wearable biometric data may capture important influences on recovery. Our objective was to evaluate whether a preoperative mHealth assessment integrating EMA with Fitbit monitoring improved predictions of spine surgery recovery., Methods: Patients age 21-85 years undergoing lumbar surgery for degenerative disease between 2021 and 2023 were recruited. For up to 3 weeks preoperatively, participants completed EMAs up to 5 times daily asking about momentary pain, disability, depression, and catastrophizing. At the same time, they were passively monitored using Fitbit trackers. Study outcomes were good/excellent recovery on the Quality of Recovery-15 (QOR-15) and a clinically important change in Patient-Reported Outcomes Measurement Information System Pain Interference 1 month postoperatively. After feature engineering, several machine learning prediction models were tested. Prediction performance was measured using the c-statistic., Results: A total of 133 participants were included, with a median (IQR) age of 62 (53, 68) years, and 56% were female. The median (IQR) number of preoperative EMAs completed was 78 (61, 95), and the median (IQR) number of days with usable Fitbit data was 17 (12, 21). 63 patients (48%) achieved a clinically meaningful improvement in Patient-Reported Outcomes Measurement Information System pain interference. Compared with traditional evaluations alone, mHealth evaluations led to a 34% improvement in predictions for pain interference (c = 0.82 vs c = 0.61). 49 patients (40%) had a good or excellent recovery based on the QOR-15. Including preoperative mHealth data led to a 30% improvement in predictions of QOR-15 (c = 0.70 vs c = 0.54)., Conclusion: Multimodal mHealth evaluations improve predictions of lumbar surgery outcomes. These methods may be useful for informing patient selection and perioperative recovery strategies., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background Context: Lateral approaches for lumbar interbody fusion (LIF) allow for access to the lumbar spine and disc space by passing through a retroperitoneal corridor either pre- or trans-psoas. A contraindication for this approach is the presence of retroperitoneal scarring that may occur from prior surgical intervention in the retroperitoneal space or from inflammatory conditions with fibrotic changes and pose challenges for the mobilization and visualization needed in this approach. However, there is a paucity of evidence on the prevalence of surgical complications following lateral fusion surgery in patients with a history of abdominal surgery., Purpose: The primary aim of this study is to describe the association between surgical complications following lateral interbody fusion surgery and prior abdominal surgical., Study Design: Retrospective study., Patient Sample: Patients over the age of 18 who underwent lateral lumbar interbody fusion at a large, tertiary care center between 2011 and 2019 were included in the study., Outcome Measures: The primary outcome included medical, surgical, and thigh-related complications either in the intraoperative or 90-day postoperative periods. Additional outcome metrics included readmission rates, length of stay, and operative duration., Methods: The electronic health records of 250 patients were reviewed for demographic information, surgical data, complications, and readmission following surgery. The association of patient and surgical factors to complication rate was analyzed using multivariable logistic regression. Statistical analysis was performed using R statistical software (R, Vienna, Austria)., Results: Of 250 lateral interbody fusion patients, 62.8% had a prior abdominal surgery and 13.8% had a history of colonic disease. The most common perioperative complication was transient thigh or groin pain/sensory changes (n=62, 24.8%). A multivariable logistic regression considering prior abdominal surgery, age, BMI, history of colonic disease, multilevel surgery, and the approach relative to psoas found no significant association between surgical complication rates and colonic disease (OR 0.40, 95% CI 0.02-2.22) or a history of prior abdominal surgeries (OR 0.56, 95% CI 0.20-1.55). Further, the invasiveness of prior abdominal surgeries showed no association with overall spine complication rate, lateral-specific complications, or readmission rates (p>.05)., Conclusion: Though retroperitoneal scarring is an important consideration for lateral approaches to the lumbar spine, this study found no association between lateral lumbar approach complication rates and prior abdominal surgery. Further study is needed to determine the impact of inflammatory colonic disease on lateral approach spine surgery., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Study Design: Observational study., Objectives: To evaluate the prevalence of erectile dysfunction and evaluate the effects of decompressive surgery on erectile dysfunction in cervical spinal stenosis and lumbar canal stenosis patients., Methods: This observational, prospective analysis enrolled patients aged 18-80 with cervical spinal stenosis and/or lumbar canal stenosis that underwent respective decompressive surgery. The IIEF-5 questionnaire was administered preoperatively, and at 6- and 12-months postoperatively to assess erectile dysfunction severity. The EPIC database was queried to determine any postoperative complications and document prominent erectile dysfunction risk factors., Results: Of 79 patients included in the analysis, 42 (53.2%) completed the IIEF-5 at 6 months, and 62 (78.5%) completed it at 12 months. Eighteen had cervical stenosis only, 54 had lumbar stenosis only, and 7 had both. 72% (18/25) of cervical stenosis patients and 83.6% (51/61) of lumbar stenosis patients had erectile dysfunction preoperatively according to IIEF-5 responses. The average preoperative IIEF-5 score indicated significant presence of erectile dysfunction for both the cervical and lumbar stenosis groups. No significant differences were identified in IIEF-5 score deltas from pre- to both postoperative periods. The presence of erectile dysfunction in both the cervical and lumbar stenosis groups was not significantly associated with the presence of any documented risk factors., Conclusions: Our results suggest no significant improvement in overall erectile function postoperatively for patients with preoperative erectile dysfunction. This is important to address during patient counseling for decompression surgery candidates with cervical spinal stenosis and/or lumbar canal stenosis to manage expectations., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

COVID-19 is a heterogenous infection-asymptomatic to fatal. While the course of pediatric COVID-19 infections is usually mild or even asymptomatic, individuals after adult heart transplantation are at high risk of a severe infection. We conducted a retrospective, multicenter survey of 16 pediatric heart transplant centers in Germany, Austria and Switzerland to evaluate the risk of a severe COVID-19 infection after pediatric heart transplantation between 02/2020 and 06/2021. Twenty-six subjects (11 male) with a median age of 9.77 years at time of transplantation and a median of 4.65 years after transplantation suffered from COVID-19 infection. The median age at time of COVID-10 infection was 17.20 years. Fourteen subjects had an asymptomatic COVID-19 infection. The most frequent symptoms were myalgia/fatigue (n = 6), cough (n = 5), rhinitis (n = 5), and loss of taste (n = 5). Only one subject showed dyspnea. Eleven individuals needed therapy in an outpatient setting, four subjects were hospitalized. One person needed oxygen supply, none of the subjects needed non-invasive or invasive mechanical ventilation. No specific signs for graft dysfunction were found by non-invasive testing. In pediatric heart transplant subjects, COVID-19 infection was mostly asymptomatic or mild. There were no SARS-CoV-2 associated myocardial dysfunction in heart transplant individuals., (© 2024 The Authors. Clinical Transplantation published by John Wiley & Sons Ltd.)

Background: Smoking cessation is challenging, despite making use of established smoking cessation therapies. Preclinical studies and one clinical pilot study suggest the antidiabetic drug glucagon-like peptide-1 (GLP-1) analogue to modulate addictive behaviours and nicotine craving. Previously, we reported the short-term results of a randomised, double-blind, placebo-controlled trial. Herein we report long-term abstinence rates and weight developments after 24 and 52 weeks., Methods: This single-centre, randomised, double-blind, placebo-controlled, parallel group trial was done at the University Hospital Basel in Switzerland. We randomly assigned (1:1) individuals with at least a moderate nicotine dependence willing to quit smoking to either a 12-week treatment with dulaglutide 1.5 mg or placebo subcutaneously once weekly in addition to standard of care smoking cessation therapy (varenicline 2 mg/day and behavioural counselling). After 12 weeks, dulaglutide or placebo injections were discontinued and the participants were followed up at week 24 and 52. The primary outcome of self-reported and biochemically confirmed point prevalence abstinence rate, and secondary outcome of secondary outcome of weight change were assessed at weeks 24 and 52. All participants who received one dose of the study drug were included in the intention to treat set and participants who received at least 10/12 doses of the study drug formed the per protocol set. The trial was registered at ClinicalTrials.gov, NCT03204396., Findings: Of the 255 participants who were randomly assigned between June 22, 2017 and December 3, 2020, 63% (80/127) (dulaglutide group) and 65% (83/128) (placebo group) were abstinent after 12 weeks. These abstinence rates declined to 43% (54/127) and 41% (52/128), respectively, after 24 weeks and to 32% (41/127) and 32% (41/128), respectively, after 52 weeks. Post-cessation weight gain was prevented in the dulaglutide group (-1.0 kg, standard deviation [SD] 2.7) as opposed to the placebo group (+1.9 kg, SD 2.4) after 12 weeks. However, at week 24, increases in weight from baseline were observed in both groups (median, interquartile range [IQR]: dulaglutide: +1.5 kg, [-0.4, 4.1], placebo: +3.0 kg, [0.6, 4.6], baseline-adjusted difference in weight change -1.0 kg (97.5% CI [-2.16, 0.16])), and at week 52 the groups showed similar weight gain (median, IQR: dulaglutide: +2.8 kg [-0.4, 4.7], placebo: +3.1 kg [-0.4, 6.0], baseline-adjusted difference in weight change: -0.35 kg (95% CI [-1.72, 1.01])). In the follow-up period (week 12 to week 52) 51 (51%) and 48 (48%) treatment-unrelated adverse events were recorded in the dulaglutide and the placebo group, respectively. No treatment-related serious adverse events or deaths occurred., Interpretation: Dulaglutide does not improve long-term smoking abstinence, but has potential to counteract weight gain after quitting. However, 3 months of treatment did not have a sustained beneficial effect on weight at 1 year. As post-cessation weight gain is highest in the first year after quitting smoking, future studies should consider a longer treatment duration with a GLP-1 analogue in abstinent individuals., Funding: Swiss National Science Foundation, the Gottfried and Julia Bangerter-Rhyner Foundation, the Goldschmidt-Jacobson Foundation, the Hemmi-Foundation, the University of Basel, the Swiss Academy of Medical Sciences., Competing Interests: All authors declare no competing interests., (© 2024 The Author(s).)

Aim: Healthcare professionals are at increased risk of burnout, primarily due to workplace-related stressors. The COVID-19 pandemic has further increased this risk. Different interventions exist with varying degrees of effectiveness; little is reported on the content and implementation of such programs. This review fills this gap, with attention to recent programs using digital components., Methods: PubMed, Embase, PsycInfo, and Google Scholar were searched between January 24th and 28th, 2022, limited to the last 5 years (≥2017). Articles were included if they (1) focused on stress reduction or burnout prevention for nurses and medical doctors within workplace health promotion for nurses or medical doctors, (2) included a digital program component, (3) were conducted in high-income country contexts, and (4) were clinical studies published in English or German. Data was extracted using a priori designed spreadsheets. A group of at least 2 authors at each stage carried out the screening, selection, and data extraction., Results: The search strategy identified 153 articles, all except 7 were excluded. Two studies were conducted in the USA, two in Spain, one in the Netherlands, Poland, and Korea each. Four studies used a randomized study design, all but one had a control group. A wide range of outcome measures was used. The types of interventions included an adapted mindfulness-based stress reduction program combined with aspects of behavioral therapies, cognitive behavioral therapy, or acceptance and commitment therapy. The digital components used were apps (4 studies), a digital platform, blended learning, and a web-based intervention (1 study each). Six studies focused on individual interventions, one included organizational interventions., Conclusion: Despite an acute burnout crisis in the healthcare sector, only seven recent interventions were found that integrated digital components. Several problems emerged during the implementation of the interventions that made it clear that organizational support is urgently needed for successful implementation. Although interventions for stress reduction and burnout prevention should combine individual and organizational measures to be as successful as possible, this was only partially the case in one of the intervention programs. The results of this scoping review can be used to further develop or optimize stress and burnout prevention programs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Adam, Berschick, Schiele, Bogdanski, Schröter, Steinmetz, Koch, Sehouli, Reschke, Stritter, Kessler and Seifert.)

Background: Lipid-lowering therapy (LLT) in patients with cardiovascular disease (CVD) is insufficient despite clear guideline recommendations. Lipid clinics have specialized in patients with dyslipidemia, but the magnitude and reduction of low-density lipoprotein cholesterol (LDL-C) in lipid clinics has not yet been studied in depth., Objective: To assess LDL-C reduction in very high-risk CVD patients achieved in a lipid clinic through different forms of LLT in comparison to standard care without the initiation of PSCK9 inhibitors., Methods: Data from 96 lipid clinic patients were analyzed retrospectively and compared to 84 standard care patients. Very high-risk patients were defined according to the European Society of Cardiology (ESC). Different combinations of LLT focusing on statins and ezetimibe were investigated. Achievement of LDL-C treatment goals according to ESC guidelines as well as LDL-C reduction were assessed., Results: Baseline and follow-up data of 180 very high-risk CVD patients (mean age 67.7 (±9.8) y; 60.6% male) were used. Achievement of the LDL-C goal in lipid clinic patients increased significantly from 14.6% at baseline to 41.7% at the latest visit (p<0.001) while standard care patients improved from 21.4% to 33.3% (p=0.08). The largest relative LDL-C reduction via an adjustment in LLT was achieved by initiation of high-intensity statins (50.8 ± 4.9%, n = 5, p < 0.05)., Conclusion: Treatment in a lipid clinic leads to a superior LDL-C goal achievement in very high-risk CVD patients as compared to standard care with the highest reduction under LLT with high-intensity statins and ezetimibe. Referral algorithms have to be established for high-risk patients., (Copyright © 2023. Published by Elsevier Inc.)

Background: Structured reporting allows a high grade of standardization and thus a safe and unequivocal report communication. In the past years, the radiological societies have started several initiatives to base radiological reports on structured reporting rather than free text reporting., Methods: Upon invitation of the working group for Cardiovascular Imaging of the German Society of Radiology, in 2018 an interdisciplinary group of Radiologists, Cardiologists, Pediatric Cardiologists and Cardiothoracic surgeons -all experts on the field of cardiovascular MR and CT imaging- met for interdisciplinary consensus meetings at the University Hospital Cologne. The aim of these meetings was to develop and consent templates for structured reporting in cardiac MR and CT of various cardiovascular diseases., Results: Two templates for structured reporting of CMR in ischemia imaging and vitality imaging and two templates for structured reporting of CT imaging for planning Transcatheter Aortic Valve Implantation (TAVI; pre-TAVI-CT) and coronary CT were discussed, consented and transferred to a HTML 5/IHR MRRT compatible format. The templates were made available for free use on the website www.befundung.drg.de., Conclusion: This paper suggests consented templates in German language for the structured reporting of cross-sectional CMR imaging of ischemia and vitality as well as reporting of CT imaging pre-TAVI and coronary CT. The implementation of these templates is aimed at providing a constant level of high reporting quality and increasing the efficiency of report generation as well as a clinically based communication of imaging results., Key Points: · Structured reporting offers a constant level of high reporting quality and increases the efficiency of report generation as well as a clinically based communication of imaging results.. · For the first time templates in German language for the structured reporting of CMR imaging of ischemia and vitality and CT imaging pre-TAVI and coronary CT are reported.. · These templates will be made available on the website www.befundung.drg.de and can be commented via strukturierte-befundung@drg.de.., Zitierweise: · Soschynski M, Bunck AC, Beer M et al. Structured Reporting in Cross-Sectional Imaging of the Heart: Reporting Templates for CMR Imaging of Ischemia and Myocardial Viability and for Cardiac CT Imaging of Coronary Heart Disease and TAVI Planning. Fortschr Röntgenstr 2023; 195: 293 - 296., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: In the absence of randomised trials for paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV2 (PIMS-TS), optimal management of PIMS-TS-patients remains somewhat uncertain. We aimed to evaluate the practicability of consensus diagnostic/therapeutic pathways in a real-life German hospital setting., Methods: All children treated for PIMS-TS (February to November, 2021) at the Childrens' Hospital Kassel were analysed retrospectively. Patients were treated according to local PIMS-TS standardised operating procedure based on the Swiss and UK consensus statements., Results: Eleven patients treated for PIMS-TS were included in this study (female:male = 2.1:1). According to the categories of the Swiss and UK consensus statements, 36% were uncomplicated hyperinflammation, 36% Kawasaki-like and 27% shock-like disease. Local estimated incidence was 0.92/1000 Covid-19 cases in children aged 4-15 years. Significant inter-group differences in laboratory parameters were found: BNP was highest in shock-like presentation compared to Kawasaki-like and uncomplicated hyperinflammation (median 954 (668-1491) versus 213 (173-934) versus 80 (5-257) ng/l, p = 0.02), whereas troponin was highest in Kawasaki-like, followed by shock-like presentation and uncomplicated hyperinflammation (median 34.7 (27.5-58.4) versus 19.1 (14.1-23.4) versus 1.9 (1.9-16.4) ng/l, p = 0.02). Patients with shock-like presentation needed circulatory resuscitation in the paediatric ICU. All patients received standardised operating procedure-based therapy and were discharged home after a medium of 7.4 days., Conclusion: The Swiss and UK consensus statements on the management of PIMS-TS proved very valuable in a real-life clinical setting, facilitated early categorisation, and initiation of specific therapy, possibly improving the outcome. Additional randomised trials are necessary to further improve the management of PIMS-TS.

Background: Quitting smoking is difficult due to barriers such as craving for cigarettes and post-cessation weight gain. Recent experimental data suggest a role of glucagon-like peptide-1 (GLP-1) in the pathophysiology of addiction in addition to appetite regulation and weight control. We hypothesized that a pharmacological intervention with the GLP-1 analogue dulaglutide during smoking cessation may improve abstinence rates and reduce post-cessation weight gain., Methods: This is a single-centre, randomized, double-blind, placebo-controlled, parallel group, superiority study conducted in the University Hospital Basel in Switzerland. We included adult smokers with at least moderate cigarette dependence who wanted to quit. Participants were randomly assigned to a 12-week treatment with dulaglutide 1.5 mg once weekly or placebo subcutaneously in addition to standard of care including behavioural counselling and oral varenicline pharmacotherapy of 2 mg/day. The primary outcome was self-reported and biochemically confirmed point prevalence abstinence rate at week 12. Secondary outcomes included post-cessation weight, glucose metabolism, and craving for smoking. All participants who received one dose of study drug were included in the primary and safety analyses. The trial was registered on ClinicalTrials.gov (NCT03204396)., Findings: Between June 22, 2017, and December 3, 2020, 255 participants were enrolled and randomly assigned to each group (127 in the dulaglutide group and 128 in the placebo group). After 12 weeks, 63% (80/127) participants on dulaglutide and 65% (83/128) on placebo treatment were abstinent (difference in proportions -1.9% [95% Confidence interval (CI) -10.7, 14.4], p-value (p) = 0.859). Dulaglutide decreased post-cessation weight (-1 kg [standard deviation (SD) 2.7]), while weight increased on placebo (+1.9 kg [SD 2.4]). The baseline-adjusted difference in weight change between groups was -2.9 kg (95% CI -3.59, -2.3, p < 0.001). Haemoglobin A1c (HbA1c) level declined on dulaglutide treatment (baseline-adjusted median difference in HbA1c between groups -0.25% [interquartile range (IQR) -0.36, -0.14], p < 0.001). Craving for smoking declined during treatment without any difference between the groups. Treatment-emergent gastrointestinal symptoms were very common in both groups: 90% (114/127) of participants on dulaglutide and 81% (81/128) on placebo)., Interpretation: Dulaglutide had no effect on abstinence rates but prevented post-cessation weight gain and decreased HbA1c levels. GLP-1 analogues may play a role in future cessation therapy targeting metabolic parameters such as weight and glucose metabolism., Funding: Swiss National Science Foundation, the Gottfried Julia Bangerter-Rhyner Foundation, the Goldschmidt-Jacobson Foundation, the Hemmi-Foundation, the University of Basel, the Swiss Academy of Medical Sciences., Competing Interests: BS declares receiving an unrestricted grant from Moderna (2022) for a study outside the submitted work. All other authors declare no competing interests., (© 2023 The Author(s).)

Mobile health (mHealth) technology has assumed a pervasive role in healthcare and society. By capturing real-time features related to spine health, mHealth assessments have the potential to transform multiple aspects of spine care. Yet mHealth applications may not be familiar to many spine surgeons and other spine clinicians. Consequently, the objective of this narrative review is to provide an overview of the technology, analytical considerations, and applications of mHealth tools for evaluating spine surgery patients. Reflecting their near-ubiquitous role in society, smartphones are the most commonly available form of mHealth technology and can provide measures related to activity, sleep, and even social interaction. By comparison, wearable devices can provide more detailed mobility and physiological measures, although capabilities vary substantially by device. To date, mHealth evaluations in spine surgery patients have focused on the use of activity measures, particularly step counts, in an attempt to objectively quantify spine health. However, the correlation between step counts and patient-reported disease severity is inconsistent, and further work is needed to define the mobility metrics most relevant to spine surgery patients. mHealth assessments may also support a variety of other applications that have been studied less frequently, including those that prevent postoperative complications, predict surgical outcomes, and serve as motivational aids to patients. These areas represent key opportunities for future investigations. To maximize the potential of mHealth evaluations, several barriers must be overcome, including technical challenges, privacy and regulatory concerns, and questions related to reimbursement. Despite those obstacles, mHealth technology has the potential to transform many aspects of spine surgery research and practice, and its applications will only continue to grow in the years ahead.

Background: Endothelial dysfunction defines outcomes and serves as a surrogate parameter for the progression of cardiovascular disease. For symptomatic peripheral artery disease (PAD) endovascular treatment is the primary revascularization strategy, which affects endothelial function. Interventional mechanical atherothrombectomy (MATH) provides advantages when treating complex atherosclerotic and thrombotic lesions. We now aimed to determine the impact and mechanisms of MATH on endothelial function. Patients and methods: Endothelial function was determined using flow-mediated dilation (FMD) before and after lower limb intervention with a six-month follow-up in the target and control vessel in 15 PAD MATH+DCB treated patients and compared to 15 non-Math controls. In a further cohort of 20 patients the impact of MATH and DCB on vascular structure and virtual histology was assessed through intravascular ultrasound (IVUS) and compared to DCB treatment alone. Results: Improved endothelial function after 6 months was observed in both groups for the target and nontarget vessel. When comparing the changes from baseline endothelial function, treatment with MATH+DCB was superior to DCB treatment in the target vessel. IVUS revealed a greater improvement in luminal area and plaque burden reduction after MATH treatment. Virtual histology disclosed MATH-associated changes in plaque composition evidenced by alterations in fibrous volume and reductions in superficial calcium. Conclusions: We demonstrate an improved endothelial function after MATH treatment as compared to DCB treatment. The improved vessel function is evidenced by MATH-related plaque burden reduction, improved luminal gain and a decrease in superficial calcification. Clinicaltrials.gov: NCT04092972.

The neutral complex dichloro-{diethyl[(5-phenyl-1,3,4-oxadiazol-2-ylamino)-(4-trifluoro-methylphenyl)methyl]phosphonate} (p-cymene)-ruthenium(II) was encapsulated inside a self-assembled hexameric host obtained upon reaction of 2,8,14,20-tetra-undecyl-resorcin[4]arene and water. The formation of an inclusion complex was inferred from a combination of spectral measurements (MS, UV/Vis spectroscopy, 1 H and DOSY NMR). The 31 P and 19 F NMR spectra are consistent with motions of the ruthenium complex inside the self-assembled capsule. Molecular dynamics simulations carried out on the inclusion complex confirmed these intra-cavity movements and highlighted possible supramolecular interactions between the ruthenium first coordination sphere ligands and the inner part (aromatic rings) of the capsule. The embedded ruthenium complex was assessed in the catalytic oxidation (using NaIO 4 as oxidant) of mixtures of three arylmethyl alcohols into the corresponding aldehydes. The reaction kinetics were shown to vary as a function of the substrates' size, with the oxidation rate varying in the order benzylalcohol >4-phenyl-benzylalcohol >9-anthracenemethanol. Control experiments realized in the absence of hexameric capsule did not allow any discrimination between the substrates., (© 2022 Wiley-VCH GmbH.)

Background: Diversity, equity, and inclusion within the healthcare workforce are conducive to providing culturally competent care. However, few existing studies have assessed the level of racial and ethnic diversity among resident physicians and residency applicants. Our objective was to provide a comparative analysis of the trends in racial and ethnic representation within different subspecialties in medicine., Methods: Using data from the American Association of Medical Colleges and the Journal of the American Medical Association, we evaluated the racial and ethnic identification of residency applicants and current residents in 9 procedural-focused specialties from 2005 to 2019 and performed a descriptive analysis to compare the different levels of racial and ethnic diversity in these specialties., Results: Among the specialties analyzed during the study period, neurosurgery had the greatest magnitude of differences between Black/African-American residency applicants and current residents. The percentage of Black/African-American applicants was 92% greater than that of Black/African-American residents (10% of applicants vs. 5.2% of residents). In contrast, the percentage of White neurosurgery residents was 17.6% greater than that of White neurosurgery applicants (53.9% of applicants vs. 63.4% of residents). Similar trends were noted in all the specialties evaluated. Obstetrics and gynecology demonstrated the least disparity between Black/African-American applicants and residents (13.7% of applicants vs. 10.2% of residents; 35.4% difference). Hispanic and Asian representation varied widely between specialties., Conclusions: Among the surveyed specialties, neurosurgery demonstrated the greatest disparity between the percentage of Black/African-American residency applicants and current residents. To further drive progress in this domain, we advocate for a series of initiatives designed to increase underrepresented minority participation in neurosurgery practice and scholarship., (Copyright © 2022. Published by Elsevier Inc.)

Study Design: Meta-analyses., Objective: This study aims to document the most common Patient-reported Outcome Measures (PROMs) used to assess lumbar fusion surgery outcomes and provide an estimate of the average improvement following surgical treatment., Summary of Background Data: As health care institutions place more emphasis on quality of care, accurately quantifying patient perceptions has become a valued tool in measuring outcomes. To this end, greater importance has been placed on the use of PROMs. This is a systemic review and meta-analysis of randomly controlled trials published between 2014 and 2019 assessing surgical treatment of degenerative spondylolisthesis., Methods: A fixed effect size model was used to calculate mean difference and a 95% confidence interval (95% CI). Linear regression was used to calculate average expected improvement, adjusted for preoperative scores., Results: A total of 4 articles (7 study groups) were found for a total of 444 patients. The 3 most common PROMs were Oswestry Disability Index (ODI) (n=7, 100%), Short-Form-12 or Short-Form-36 (SF-12/36) (n=4, 57.1%), and visual analog scale-back pain (n=3, 42.8%). Pooled average improvement was 24.12 (95% CI: 22.49-25.76) for ODI, 21.90 (95% CI: 19.71-24.08) for SF-12/36 mental component score, 22.74 (95% CI: 20.77-24.71) for SF-12/36 physical component score, and 30.87 (95% CI: 43.79-47.97) for visual analog scale-back pain. After adjusting for preoperative scores, patients with the mean preoperative ODI (40.47) would be expected to improve by 22.83 points postoperatively., Conclusions: This study provides a range of expected improvement for common PROMs used to evaluate degenerative spondylolisthesis with the goal of equipping clinicians with a benchmark value to use when counseling patients regarding surgery. In doing so, it hopes to provide a comparison point by which to judge individual patient improvement., Level of Evidence: Level II., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Heart failure (HF) due to myocarditis might not respond in the same way to standard therapy as HF due to other aetiologies. The aim of this study was to investigate the value of endomyocardial biopsies (EMB) for clinical decision-making and its relation to the outcome of paediatric patients with myocarditis., Methods: Clinical and EMB data of children with myocarditis collected for the MYKKE-registry between 2013 and 2020 from 23 centres were analysed. EMB studies included histology, immunohistology, and molecular pathology. The occurrence of major adverse cardiac events (MACE) including mechanical circulatory support (MCS), heart transplantation, and/or death was defined as a combined endpoint., Results: Myocarditis was diagnosed in 209/260 patients: 64% healing/chronic lymphocytic myocarditis, 23% acute lymphocytic myocarditis (AM), 14% healed myocarditis, no giant cell myocarditis. The median age was 12.8 (1.4-15.9) years. Time from symptom-onset to EMB was 11.0 (4.0-29.0) days. Children with AM and high amounts of mononuclear cell infiltrates were significantly younger with signs of HF compared to those with healing/chronic or healed myocarditis. Myocardial viral DNA/RNA detection had no significant effect on outcome. The worst event-free survival was seen in patients with healing/chronic myocarditis (24%), followed by acute (31%) and healed myocarditis (58%, p = 0.294). A weaning rate of 64% from MCS was found in AM., Conclusions: EMB provides important information on the type and stage of myocardial inflammation and supports further decision-making. Children with fulminant clinical presentation, high amounts of mononuclear cell infiltrates or healing/chronic inflammation and young age have the highest risk for MACE., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Multiple sclerosis (MS) is an autoimmune inflammatory disease that results in demyelination of the central nervous system (CNS). MS affects as many as 350,000 individuals in the United States and commonly presents before the age of 45 years. Patients with MS, as the general population, are likely to encounter degenerative changes of the spine as they age, and this can pose a unique challenge to both patients with MS and physicians, as both conditions can have a great deal of symptomatic overlap despite stark differences in management. Currently there is no definitive approach that allows physicians to distinguish between the 2 conditions; however, specific clinical and radiologic findings have been identified as being useful in evaluating these patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This preliminary randomized clinical trial explores the efficacy of task-oriented electromyography (EMG)-triggered multichannel functional electrical stimulation (EMG-MES) compared to single-channel cyclic neuromuscular electrical stimulation (cNMES) on regaining control of voluntary movements (CVM) and the ability to execute arm-hand-activities in subacute stroke patients with moderate arm paresis. Twelve ischemic stroke patients (Fugl-Meyer Assessment Arm Section (FMA-AS) score: 19-47) with comparable demographics were block-randomized to receive 15 sessions of cNMES or EMG-MES over three weeks additionally to a conventional neurorehabilitation program including task-oriented arm training. FMA-AS, Box-and-Block Test (BBT), and Stroke-Impact-Scale (SIS) were recorded at baseline and follow-up. All participants demonstrated significant improvement in FMA-AS and BBT. Participants treated with EMG-MES had a higher mean gain in FMA-AS than those treated with cNMES. In the SIS daily activities domain, both groups improved non-significantly; participants in the EMG-MES group had higher improvement in arm-hand use and stroke recovery. EMG-MES treatment demonstrated a higher gain of CVM and self-reported daily activities, arm-hand use, and stroke recovery compared to cNMES treatment of the wrist only. The protocol of this proof-of-concept study seems robust enough to be used in a larger trial to confirm these preliminary findings.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objectives: Quantitative evaluations of function, volume and mass are fundamental in the diagnostic workup of different cardiovascular diseases and can be exactly determined by CMRI in sinus rhythm. This does not hold true in arrhythmia as CMR is hampered by reconstruction artifacts caused by inconsistent data from multiple heartbeats. Real-time (RT) MRI at high temporal resolution might reduce these problems., Methods: Consecutive patients with atrial fibrillation were prospectively included and underwent RT and conventional CINE CMR in randomized order. 29 patients were studied at 1.5 T and 30 patients at 3 T. At 3 T a group of 20 subjects in sinus rhythm served as controls. RT and CINE image quality was evaluated in different planes and for different wall sections using a Likert scale (from zero to four). Volumetric analysis was performed using two types of software and differences between RT and CINE CMR were evaluated., Results: In patients with atrial fibrillation RT CMR short axis (SA) resulted in a significantly higher image quality compared to CINE imaging both at 1.5 T and 3 T (1.5 T: mid SA: 3.55 ± 0.5 RT vs 2.6 ± 0.9 CINE, p = 0.0001; 3 T: mid SA: 3.15 ± 0.9 RT vs 2.6 ±1.0 CINE, p = 0.03); This qualitative difference was more marked and significant for the long axis views (2CV and 4CV) at 1.5 T (1.5 T: 2CV: 3.2 ± 0.6 RT vs 2.65 ± 1.1 CINE; p = 0.011; 4CV: 2.9 ± 0.69 RT vs 2.4 ± 0.9 CINE; p = 0.0044). During sinus rhythm CINE images were superior concerning diagnostic quality (3 T mid SA: 3.35 ± 0.45 RT vs 3.8 ± 0.5 CINE, p = 0.008). Quantitative analysis was successful with both software packages and the results showed a good correlation (Pearson correlation between 0.679 and 0.921 for patients). RT CMR resulted in slightly lower functional volumes than CINE CMR (3 T: patients: EDVI 86 ± 29 ml/m 2 RT vs 93 29 ml/m 2 ± 29 CINE, Pearson r = 0.902) but similar ejection fractions (3 T: patients: EF 47 ± 16% RT vs 45 ± 13% CINE, Pearson r = 0679; controls: EF 63 ± 6 RT vs 63 ± 3 CINE, Pearson r = 0.695)., Conclusion: RT CMR improves image quality in arrhythmic patients and renders studies more comfortable. Volumetric analysis is feasible with slightly lower values relative to CINE CMR, while ejection fractions are comparable., (© 2022 The Authors.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

As the percentage of overweight individuals in the population rises, diseases associated with excess weight resulting from poor nutrition are becoming more and more widespread. So far, the influence of weight or nutrition on bone health has shown conflicting results. In the literature, the existing studies disagree about the effect of diet on bones. Therefore, this study investigated the impact of a long-term, high-fat, and high-cholesterol diet on the spine in a mouse model. Wild-type mice were randomly separated into two groups; one group received a high-fat and high-cholesterol diet, and a control group was fed with a regular diet since birth for a duration of 8 months. The first to fifth thoracic vertebrae were extracted and investigated using histology and micro-CT. Samples were analyzed regarding different parameters: percentage of bone structure compared to the whole vertebra and the amount and thickness of the trabeculae. Both methods of the analysis showed similar results. Diet did not have a significant impact on the bone density of the vertebrae. The micro-CT examination showed that the average bone percentage of the examined vertebra was 6% (p = 0.2330) higher in the control group compared to the diet group. The same tendency was demonstrated in histology even though with a smaller difference of only 5%. The results of both methods were comparable and showed trends for the influence of different diets but not significant impacts. In summary, this study showed that a high-fat and high-cholesterol diet has a slightly negative impact on bone density. In order to further analyze the effects of different diets on bone composition, structure, and density, additional long-term studies should be carried out, and more parameters such as movement and genetic factors should be analyzed. Furthermore, other parameters such as exercise and genetic factors that could have a secondary influence on obesity should be investigated., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Aim: Due to improved therapy in childhood, many patients with congenital heart disease reach adulthood and are termed adults with congenital heart disease (ACHD). ACHD often develop heart failure (HF) as a consequence of initial palliative surgery or complex anatomy and subsequently require advanced HF therapy. ACHD are usually excluded from trials evaluating heart failure therapies, and in this context, more data about heart failure trajectories in ACHD are needed to guide the management of ACHD suffering from HF., Methods and Results: The pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA-R) will collect data from ACHD evaluated or listed for heart or heart-combined organ transplantation from 16 countries in Europe and the Asia/Pacific region. We plan retrospective collection of data from 1989-2020 and will include patients prospectively. Additional organizations and hospitals in charge of transplantation of ACHD will be asked in the future to contribute data to the register. The primary outcome is the combined endpoint of delisting due to clinical worsening or death on the waiting list. The secondary outcome is delisting due to clinical improvement while on the waiting list. All-cause mortality following transplantation will also be assessed. The data will be entered into an electronic database with access to the investigators participating in the register. All variables of the register reflect key components important for listing of the patients or assessing current HF treatment., Conclusion: The ARTORIA-R will provide robust information on current management and outcomes of adults with congenital heart disease suffering from advanced heart failure., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Treatment of symptomatic peripheral artery disease (PAD) through endovascular interventions is the primary revascularization strategy. Interventions restore perfusion but may cause severe injury to the vascular endothelium, which regulates vascular tone. Endothelial dysfunction is involved in the progression of cardiovascular disease, with higher incidences of vascular events. We aimed to determine the impact of percutaneous interventions on change in endothelial function. Patients and methods: Endothelial function was determined using flow-mediated dilation (FMD) before, the day after lower limb intervention with paclitaxel-coated balloons or stent guided interventions and after a six-month follow-up in the target limb, control limb and the systemic circulation in 42 PAD patients aged 70.2±9 years and 66% men. Additionally, macro- and microvascular function were assessed. Results: In PAD patients aged 70.2±9 years and 66% men, we observed an immediate enhancement of macro-, microvascular and endothelial function after endovascular treatment (FMD of superficial femoral artery (SFA) 3.7±0.2% to 4.1±0.1%, n=42, p=0.02), a sustained long-term improvement after 6-months (FMD SFA 3.7±0.2% to 4.2±0.1%, n=42, p=0.01), and moreover an improved systemic endothelial function (FMD brachial artery 4.3±0.1% to 4.7±0.2, n=42, p=0.01) following peripheral interventions. Subgroup analysis however revealed that following paclitaxel-based percutaneous intervention, the paclitaxel dosage applied was inversely related to the chronic improvement in local endothelial function (r=-0.6, n=22, p=0.005) without evidence for systemic effects (r=-0.25, p=0.27). Conclusions: We demonstrate an improved local and systemic endothelial function after treatment of atherosclerotic peripheral disease with a distinguished response after endovascular intervention with higher dosage of applied paclitaxel restraining the benefits. Further studies have to determine the optimal interventional strategy with respect to different treatment modalities to maintain vessel functions.

Background: The coronavirus disease 2019 (COVID-19) pandemic has changed health care delivery across the United States. Few analyses have specifically looked at quantifying the financial impact of the pandemic on practicing neurosurgeons. A survey analysis was performed to address this need., Methods: A 19-question survey was distributed to practicing neurosurgeons in the United States and its territories. The questions evaluated respondents' assessments of changes in patient and procedural volume, salary and benefits, practice expenses, staffing, applications for government assistance, and stroke management. Responses were stratified by geographic region., Results: The response rate was 5.1% (267/5224). Most respondents from each region noted a >50% decrease in clinic volume. Respondents from the Northeast observed a 76% decrease in procedure volume, which was significantly greater than that of other regions (P = 0.003). Northeast respondents were also significantly more likely to have been reassigned to nonneurosurgical clinical duties during the pandemic (P < 0.001). Most respondents also noted decreased salary and benefits but experienced no changes in overall practice expenses. Most respondents did not experience significant reductions in nursing or midlevel staffing. These trends were not significantly different between regions., Conclusions: The COVID-19 pandemic has led to decreases in patient and procedural volume and physician compensation despite stable practice expenses. Significantly more respondents in the Northeast region noted decreases in procedural volume and reassignment to nonneurosurgical COVID-related medical duties. Future analysis is necessary as the pandemic evolves and the long-term clinical and economic implications become clear., (Copyright © 2021. Published by Elsevier Inc.)

Background: Mobile health interventions are intended to support complex health care needs in chronic diseases digitally, but they are mainly targeted at general health improvement and neglect disease-specific requirements. Therefore, we designed TrackPAD, a smartphone app to support supervised exercise training in patients with peripheral arterial disease., Objective: This pilot study aimed to evaluate changes in the 6-minute walking distance (meters) as a primary outcome measure. The secondary outcome measures included changes in physical activity and assessing the patients' peripheral arterial disease-related quality of life., Methods: This was a pilot two-arm, single-blinded, randomized controlled trial. Patients with symptomatic PAD (Fontaine stage IIa/b) and access to smartphones were eligible. Eligible participants were randomly assigned to the study, with the control group stratified by the distance covered in the 6-minute walking test using the TENALEA software. Participants randomized to the intervention group received usual care and the mobile intervention (TrackPAD) for the follow-up period of 3 months, whereas participants randomized to the control group received routine care only. TrackPAD records the frequency and duration of training sessions and pain levels using manual user input. Clinical outcome data were collected at the baseline and after 3 months via validated tools (the 6-minute walk test and self-reported quality of life). The usability and quality of the app were determined using the Mobile Application Rating Scale user version., Results: The intervention group (n=19) increased their mean 6-minute walking distance (83 meters, SD 72.2), while the control group (n=20) decreased their mean distance after 3 months of follow-up (-38.8 meters, SD 53.7; P=.01). The peripheral arterial disease-related quality of life increased significantly in terms of "symptom perception" and "limitations in physical functioning." Users' feedback showed increased motivation and a changed attitude toward performing supervised exercise training., Conclusions: Besides the rating providing a valuable support tool for the user group, the mobile intervention TrackPAD was linked to a change in prognosis-relevant outcome measures combined with enhanced coping with the disease. The influence of mobile interventions on long-term prognosis must be evaluated in the future., Trial Registration: ClinicalTrials.gov NCT04947228; https://clinicaltrials.gov/ct2/show/NCT04947228., (©Katrin Paldán, Martin Steinmetz, Jan Simanovski, Christos Rammos, Greta Ullrich, Rolf Alexander Jánosi, Susanne Moebus, Tienush Rassaf, Julia Lortz. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 16.08.2021.)

Objectives: Among changes in demographics, aging is the most relevant cardiovascular risk factor. The prevalence of peripheral artery disease (PAD) is high in elderly patients and is associated with a worse prognosis. Despite optimal treatments, mortality in the high-risk population of octo- and nonagenarians with PAD remains excessive, and predictive factors need to be identified. The objective of this study was to investigate predictors of mortality in octo- and nonagenarians with PAD., Methods: Cases of treated octo- and nonagenarians, including the clinical characteristics and markers of myocardial injury and heart failure, were studied retrospectively with respect to all-cause mortality. Hazard ratios [HR] were calculated and survival was analyzed by Kaplan-Meyer curves and receiver operating characteristic curved were assessed for troponin-ultra and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and chronic limb-threatening ischemia (CLTI)., Results: A total of 123 octo- and nonagenarians admitted for PAD were eligible. The troponin level was the major predictor of all-cause mortality (HR: 4.6, 95% confidence interval [CI]: 1.4-15.3), followed by the NT-proBNP level (HR: 3.9, 95% CI 1.8-8.8) and CLTI (HR: 3.1, 95% CI 1.6-5.9). Multivariate regression revealed that each increment of 1 standard deviation in log troponin and log NT-proBNP was associated with a 2.7-fold (95% CI 1.8-4.1) and a 1.9-fold (95% CI 1.2-2.9) increased risk of all-cause death. Receiver operating characteristic curve analysis using a combination of all predictors yielded an improved area under the curve of 0.888. In a control group of an equal number of younger individuals, only NT-proBNP (HR: 4.2, 95% CI 1.2-14.1) and CLTI (HR: 6.1, 95% CI 1.6-23.4) were predictive of mortality., Conclusion: Our study demonstrates that cardiovascular biomarkers and CLTI are the primary predictors of increased mortality in elderly PAD patients. Further risk stratification through biomarkers in this high-risk population of octo- and nonagenarians with PAD is necessary., (© 2021. The Author(s).)

Background: Correction of tetralogy of Fallot (cTOF) often results in pulmonary valve pathology and right ventricular (RV) dysfunction. Reduced exercise capacity in cTOF patients cannot be explained by these findings alone. We aimed to explore why cTOF patients exhibit impaired exercise capacity with the aid of a comprehensive cardiopulmonary exercise testing (CPET) and real-time cardiovascular magnetic resonance exercise testing (CMR-ET) protocol., Methods: Thirty three cTOF patients and 35 matched healthy controls underwent CPET and CMR-ET in a prospective case-control study. Real-time steady-state free precession cine and phase-contrast sequences were obtained during incremental supine in-scanner cycling at 50, 70, and 90 W. RV and left ventricle (LV) volumes and pulmonary blood flow (Qp) were calculated. Differences of CPET and CMR-ET between cTOF versus controls and correlations between CPET and CMR-ET parameters in cTOF were evaluated statistically for all CMR exercise levels using Mann-Whitney U and Spearman rank-order correlation tests., Results: CPET capacity was significantly lower in cTOF than in controls. cTOF patients exhibited not only significantly reduced Qp and RV function but also lower LV function on CMR-ET. Higher CPET values in cTOF correlated with higher Qp (Qp 90 W versus carbon dioxide ventilatory equivalent %: R =-0.519, P <0.05), higher LV-end-diastolic volume indexed to body surface area (LV-end-diastolic volume indexed to body surface area at 50 W versus oxygen uptake in % at maximum exercise on CPET R =0.452, P <0.05), and change in LV ejection fraction (EF; LV-EF at 90 W versus Watt %: r =-0.463, P <0.05). No correlation was found with regard to RV-EF. Significant RV-LV interaction was observed during CMR-ET (RV-EF versus LV-EF at 50 W and 70 W: r =0.66, P <0.02 and r =0.52, P <0.05, respectively)., Conclusions: Impaired exercise capacity in cTOF resulted from a reduction in not only RV, but also LV function. cTOF with good exercise capacity on CPET demonstrated higher LV reserve and pulmonary blood flow during incremental CMR-ET. Apart from RV parameters, CMR-ET-derived LV function could be a valuable tool to stratify cTOF patients for pulmonary valve replacement.

Bertolotti Syndrome is a diagnosis given to patients experiencing pain caused by the presence of a lumbosacral transitional vertebra (LSTV), which is characterized by enlargement of the L5 transverse process(es), with potential pseudoarticulation or fusion with the sacrum. The Castellvi classification system is commonly utilized to grade LSTVs based on the degree of contact between the L5 transverse process(es) and the sacrum. LSTVs present a diagnostic dilemma to the treating clinician, as they may remain unidentified on plain x-rays and even advanced imaging; additionally, even if the malformation is identified, patients with a LSTV may be asymptomatic or have nonspecific symptoms, such as low back pain with or without radicular symptoms. With low back pain being extremely prevalent in the general population; it can be difficult to implicate the LSTV as the source of this pain. Care should be taken however, to exclude Bertolotti Syndrome in patients under 30 years old presenting with persisting low back pain given its congenital origin. If a LSTV is identified, typically with acquisition of a MRI or CT scan of the lumbosacral spine, and there is an absence of a more compelling or obvious source for the patient's symptoms, a conservative, step-wise management plan is recommended. This may include assessing for improvement in symptoms with injections prior to proceeding with surgical intervention. Additional concerns arise from the biomechanical alterations that a LSTV induces in adjacent spinal levels, predisposing this patient population to a more rapid-onset of adjacent segment disease, raising the question as to the most appropriate surgery (resection of LSTV pseudoarticulation with or without fusion). Postoperative outcome data for patients undergoing surgical treatment is limited in the literature with promising, but variable, results. More large-scale, controlled studies must be performed to gain further insight into the ideal work-up and management of this pathology., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Credentialing and certification are essential processes during hiring to ensure that the physician is competent and possesses the qualifications and skill sets claimed. Peer review ensures the continuing evolution of these skills to meet a standard of care. We have provided an overview and discussion of these processes in the United States. Credentialing is the process by which a physician is determined to be competent and able to practice, used to ensure that medical staff meets specific standards, and to grant operative privileges at an institution. Certification is a standardized affirmation of a physician's competence on a nationwide basis. Although not legally required to practice in the United States, many institutions emphasize certification for full privileges on an ongoing basis at a hospital. In the United States, peer review of adverse events is a mandatory prerequisite for accreditation. The initial lack of standardization led to the development of the Health Care Quality Improvement Act, which protects those involved in the peer review process from litigation, and the National Provider Databank, which was established as a national database to track misconduct. A focus on quality improvement in the peer review process can lead to improved performance and patient outcomes. A thorough understanding of the processes of credentialing, certification, and peer review in the United States will benefit neurosurgeons by allowing them to know what institutions are looking for as well and their rights and responsibilities in any given situation. It could also be useful to compare these policies and practices in the United States to those in other countries., (Copyright © 2021. Published by Elsevier Inc.)

Objective: The Council of State Neurosurgical Societies surveyed neurosurgeons applying for oral board certification in 2008 to assess their preparedness to practice. This survey was repeated in 2013 for a subsequent group of board applicants to evaluate the quality of neurosurgery training and identify opportunities for improvement., Methods: Applicants for the American Board of Neurological Surgeons oral examination from 2008 to 2013 were provided an anonymous survey focused on clinical and socioeconomic skills. Survey responses were compared with the published results of a similar survey using an inferential statistical analysis., Results: In total, 110 of 655 neurosurgeons responded (response rate 16.8%). Significantly more respondents from the 2013 survey felt prepared to perform the following techniques: angiography, endoscopic surgery, anterior lumbar interbody fusion, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion, kyphoplasty, and deep brain stimulation. Significantly more respondents in 2013 attested to receiving appropriate education on Health Insurance Portability and Accountability Act and pay-for-performance practice models of health care. However, significantly fewer respondents in 2013 felt prepared in open vascular neurosurgery techniques. In both surveys, fewer than 35% of respondents felt adequately prepared in endovascular neurosurgery techniques, medical coding, negotiating an employment contract, and issues regarding practice management and the economics of neurosurgery., Conclusions: The 2013 survey suggests that candidates for board certification in neurosurgery perceive themselves to be adequately prepared to independently perform nearly all neurosurgical procedures. However, additional work is required to optimize neurosurgery training in endovascular procedures and the socioeconomic aspects of neurosurgery practice., (Copyright © 2021. Published by Elsevier Inc.)

Background: Peripheral artery disease (PAD) patients have high morbidity and mortality rates, demonstrating a need for improved treatment strategies. While underuse and undertreatment have been reported, there is no clear picture of patterns in population-level disease prevalence, prescription of guideline-recommended pharmacotherapy, or frequency of contact with dedicated specialists. We present population-level data on changes in prevalence, care and treatment of PAD from 2009 to 2018 in Germany., Methods: We analyzed the ambulatory claims data for all statutorily insured patients comprising 70.1 million patients each year and 87% of the German population. Prevalence was assessed by documentation of PAD and stratified by age and sex within the 10-year study timeframe. In addition, current ambulatory care, stratified by vascular specialists (vascular surgeons or angiologists), internists, cardiologists and primary care physicians, were examined., Findings: Prevalence increased from 1·85% in 2009 to 3·14% in 2018, affecting 2·3 million patients in 2018 and more males (55%) than females (45%). A low level of visits to vascular specialists, with 11·1% receiving care from vascular surgeons and 8·1% from angiologists, was shown. Moreover, analysis of guideline-recommended prescriptions revealed increasing, but still insufficient, prescription frequencies among PAD patients between 2009 and 2016, from 42·6% to 56% for statins and from 40·2% to 48·0% for antiplatelets., Interpretation: Our results show that the prevalence of PAD in Germany, as assessed by outpatient PAD documentation, is increasing and PAD patients are underutilizing specialized vascular care; moreover, the prescription frequency of guideline-recommended therapies remains low. There is a clear need to improve the referral and treatment algorithms in the high-risk PAD population., Funding: None., Competing Interests: All authors declare no conflict of interest., (© 2021 The Authors.)

Background: Right heart catheterization using exercise stress is the reference standard for the diagnosis of heart failure with preserved ejection fraction (HFpEF) but carries the risk of the invasive procedure. We hypothesized that real-time cardiac magnetic resonance (RT-CMR) exercise imaging with pathophysiologic data at excellent temporal and spatial resolution may represent a contemporary noninvasive alternative for diagnosing HFpEF., Methods: The HFpEF-Stress trial (CMR Exercise Stress Testing in HFpEF; URL: https://www.clinicaltrials.gov; Unique identifier: NCT03260621. URL: https://dzhk.de/; Unique identifier: DZHK-17) prospectively recruited 75 patients with echocardiographic signs of diastolic dysfunction and dyspnea on exertion (E/e'>8, New York Heart Association class ≥II) to undergo echocardiography, right heart catheterization, and RT-CMR at rest and during exercise stress. HFpEF was defined according to pulmonary capillary wedge pressure (≥15 mm Hg at rest or ≥25 mm Hg during exercise stress). RT-CMR functional assessments included time-volume curves for total and early (1/3) diastolic left ventricular filling, left atrial (LA) emptying, and left ventricular/LA long axis strain., Results: Patients with HFpEF (n=34; median pulmonary capillary wedge pressure at rest, 13 mm Hg; at stress, 27 mm Hg) had higher E/e' (12.5 versus 9.15), NT-proBNP (N-terminal pro-B-type natriuretic peptide; 255 versus 75 ng/L), and LA volume index (43.8 versus 36.2 mL/m 2 ) compared with patients with noncardiac dyspnea (n=34; rest, 8 mm Hg; stress, 18 mm Hg; P ≤0.001 for all). Seven patients were excluded because of the presence of non-HFpEF cardiac disease causing dyspnea on imaging. There were no differences in RT-CMR left ventricular total and early diastolic filling at rest and during exercise stress ( P ≥0.164) between patients with HFpEF and noncardiac dyspnea. RT-CMR revealed significantly impaired LA total and early ( P <0.001) diastolic emptying in patients with HFpEF during exercise stress. RT-CMR exercise stress LA long axis strain was independently associated with HFpEF (adjusted odds ratio, 0.657 [95% CI, 0.516-0.838]; P =0.001) after adjustment for clinical and imaging measures and emerged as the best predictor for HFpEF (area under the curve at rest 0.82 versus exercise stress 0.93; P =0.029)., Conclusions: RT-CMR allows highly accurate identification of HFpEF during physiologic exercise and qualifies as a suitable noninvasive diagnostic alternative. These results will need to be confirmed in multicenter prospective research studies to establish widespread routine clinical use. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03260621. URL: https://dzhk.de/; Unique identifier: DZHK-17.

Colorectal cancer (CRC) is a heterogeneous disease, which in part explains the differential response to chemotherapy observed in the clinic. BH3 mimetics, which target anti-apoptotic BCL-2 family members, have shown potential in the treatment of hematological malignancies and offer promise for the treatment of solid tumors as well. To gain a comprehensive understanding of the response to BH3 mimetics in CRC and the underlying molecular factors predicting sensitivity, we screened a panel of CRC cell lines with four BH3 mimetics targeting distinct anti-apoptotic BCL-2 proteins. Treatment with compounds alone and in combination revealed potent efficacy of combined MCL-1 and BCL-XL inhibition in inducing CRC cell death, irrespective of molecular features. Importantly, expression of the anti-apoptotic protein target of BH3 mimetics on its own did not predict sensitivity. However, the analysis did identify consensus molecular subtype (CMS) specific response patterns, such as higher resistance to single and combined BCL-2 and MCL-1 inhibition in CMS2 cell lines. Furthermore, analysis of mutation status revealed that KRAS mutant cell lines were more resistant to MCL-1 inhibition. Conclusively, we find that CRC cell lines presented with distinct responses to BH3 mimetics that can in part be predicted by their CMS profile and KRAS / BRAF mutations. Overall, almost all CRC lines share sensitivity in the nanomolar range to combined MCL-1 and BCL-XL targeting suggesting that this would be the preferred approach to target these cancers.

Background: The avoidance of prolonged hospital stay is a major goal in the management of transcatheter aortic valve implantation (TAVI) - medically and economically. Materials & methods: We compared the time range of the preprocedural length of stay in 2014/2015 with 2016/2017, after the implementation of the TAVI coordinator in 2016. This included restructured pathways for screening and pre-interventional diagnosis, performed examinations during the inpatient stay and major outcome variables. Results: After 2016, we observed a significant reduction in preprocedural length of stay (admission to procedure) compared with 2014/2015 (11.3 ± 7.9 vs 7.5 ± 5.6 days, p = 0.001). There was no difference in other major outcome variables. Conclusion: The introduction of the TAVI coordinator caused a shortening of preprocedural length of stay.

BACKGROUND Atherosclerosis and malignancies are leading causes of morbidity and mortality worldwide. In lower-extremity arterial disease (LEAD), progressing or ruptured atherosclerotic plaques are the main culprit for limb ischemia and may cause claudication, chronic wounds, or necrotic lesions. In those cases, standard of care includes revascularization in addition to best medical therapy. Other sources for acute or chronic limb ischemia different from atherosclerosis are often overlooked, especially once atherosclerotic plaques have been detected. CASE REPORT We report the rare case of a patient presenting with painful necrotic ulcerations of the lower extremity due critical essential thrombocythemia that was complicated by an atherosclerotic disease. Based on the clinical presentation, 4 major differential diagnoses were initially considered: Martorell's ulcer, pyoderma gangrenosum, LEAD, and recurrent thromboembolic occlusions due to a malignant disease. Following a thorough, holistic diagnostic work-up, we identified the first diagnosis of critical essential thrombocythemia, which was aggravated by LEAD. CONCLUSIONS This case report highlights the importance of taking malignancies into consideration as a differential diagnosis in patients with repetitive arterial occlusions. With a broad variety of differential diagnoses to be considered for the presented ulcerations, this case report highlights the crucial importance of a rapid interdisciplinary approach to treat and relieve symptoms and prevent further arterial thrombotic events. The learning objective is to give a clear diagnostic work-up to navigate through the most important differential diagnoses of non-atherosclerotic conditions aggravating LEAD.

Brachial plexus (BP) tumors are rare, potentially difficult-to-manage lesions. The method is retrospective chart analysis. Among the 17 patients, four had neurofibromatosis and one schwannomatosis (NF +). The latter has bilateral BP tumors that remain stable on MRI at a 6.5 year follow-up. Another NF + patient has bilateral non-operable BP plexiform neurofibromas. The complaints of the 15 operated patients were radiated pain, a mass, local pain, paresthesia, a neurological deficit (n = 15, 12, 7, 10, 7). On MRI, the tumors appeared as nodular or ovoid large masses. Four operated tumors were proximal, reaching the foramen. The FDG-PET scan (n = 4) always showed tumor hypermetabolism. A preoperative percutaneous biopsy was done in three patients before neurosurgical consultation; one of them developed neurogenic pain and a sensory deficit following two percutaneous biopsies for a misinterpreted cervical lymphadenopathy. Surgery was performed using a supra-, infra-, supra- + infra-clavicular or posterior subscapular approach (n = 8, 3, 3, 1). Intraoperative electrophysiology was used in all patients. Complete or gross total resection was achieved in 14 patients. Two patients had fascicle reconstruction with grafts. Pathology revealed 13 schwannomas and two neurofibromas. Neurogenic pain transiently developed or worsened after surgery in five patients. At last follow-up, a mild deficit remained in four patients (preexisting in three). No recurrence had occurred. We conclude that a thorough examination of any patient with a cervical or axillary mass is crucial to avoid misinterpretation as a lymphadenopathy. MRI is the best imaging modality. Most BP benign tumors can be completely and safely resected through the use of microsurgical techniques and intraoperative electrophysiology.

Objective: To analyze the management of iatrogenic nerve injuries (iNI) in 42 patients., Methods: Retrospective analysis of the charts., Results: The iNI occurred mostly during a surgical procedure (n = 39), either on a nerve or plexus (n = 13), on bone, joint, vessel or soft tissue (n = 24) or because of malpositioning (n = 2). The most commonly injured nerves were the brachial plexus, radial, sciatic, femoral, or peroneal nerves. 42.9% of the patients were referred later than 6 months. A neurological deficit was present in 37 patients and neuropathic pain in 17. Two patients were lost to follow-up. Conservative treatment was applied in 23 patients because of good spontaneous recovery or compensation or because of expected bad prognosis whatever the treatment. Surgical treatment was performed in 17 patients because of known nerve section (n = 2), persistent neurological deficit (n = 12) or invalidating neuropathic pain (n = 3); nerve reconstruction with grafts (n = 8) and neurolysis (n = 8) were the most common procedures. Outcome was satisfactory in 50%. Potential reasons of poor outcome were a very proximal injury, placement of very long grafts, delayed referral and predominance of neuropathic pain. According to the literature delayed referral of iNI for treatment is frequent. We provide an illustrative case of a young girl operated on at 6.5 months for femoral nerve reconstruction with grafts while nerve section was obvious from the operative note and pathological tissue analysis. Litigation claims (n = 10) resulted in malpractice (n = 2) or therapeutic alea (n = 5) (3 unavailable conclusions). i CONCLUSIONS: NI can result in considerable disability, pain and litigation. Optimal management is required.

Objective: To perform an ecological study to analyze the geospatial distribution of neurosurgeons ≥60 years old and compare these data with the spread of 2019 novel coronavirus disease (COVID-19) across the United States., Methods: Data regarding distribution of COVID-19 cases were collected from the Environmental Systems Research Institute, and demographic statistics were collected from the American Association of Medical Colleges 2019 State Workforce Reports. These figures were analyzed using geospatial mapping software., Results: As of July 5, 2020, the 10 states with the highest number of COVID-19 cases showed older neurosurgical workforce proportions (the proportion of active surgeons ≥60 years old) of 20.6%-38.9%. Among states with the highest number of COVID-19 deaths, the older workforce proportions were 25.0%-43.4%. Connecticut demonstrated the highest with 43.4% of neurosurgeons ≥60 years old., Conclusions: Regional COVID-19 hotspots may coincide with areas where a substantial proportion of the neurosurgical workforce is ≥60 years old. Continuous evaluation and adjustment of local and national clinical practice guidelines are warranted throughout the pandemic era., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The therapeutic success in patients with congenital heart disease (CHD) leads to a growing number of adults with CHD (adult CHD [ACHD]) who develop end-stage heart failure. We aimed to determine patient characteristics and outcomes of ACHD listed for heart transplantation., Methods: Using data from all the patients with ACHD in 20 transplant centers in the Eurotransplant region from 1999 to 2015, we analyzed patient characteristics, waiting list, and post-transplantation outcomes., Results: A total of 204 patients with ACHD were listed during the study period. The median age was 38 years, and 62.3% of the patients were listed in high urgency (HU), and 37.7% of the patients were in transplantable (T)-listing status. A total of 23.5% of the patients died or were delisted owing to clinical worsening, and 75% of the patients underwent transplantation. Median waiting time for patients with HU-listing status was 4.18 months and with T-listing status 9.07 months. There was no difference in crude mortality or delisting between patients who were HU status listed and T status listed (p = 0.65). In multivariable regression analysis, markers for respiratory failure (mechanical ventilation, hazard ratio [HR]: 1.41, 95% CI: 1.11-1.81, p = 0.006) and arrhythmias (anti-arrhythmic medication, HR: 1.42, 95% CI: 1.01-2.01, p = 0.044) were associated with a higher risk of death or delisting. In the overall cohort, post-transplantation mortality was 26.8% after 1 year and 33.4% after 5 years., Conclusions: Listed patients are at high risk of death without differences in the urgency of listing. Respiratory failure requiring invasive ventilation and possibly arrhythmias requiring anti-arrhythmic medication indicate worse outcomes on waiting list., (Copyright © 2020 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background : The transradial artery approach is the preferred access for cardiac catheterization according to current guidelines. However, the most common complication is radial artery occlusion (RAO). Despite the rare indication for surgical reopening, the occluded radial artery is not available for further procedures or as a potential bypass graft. Still, treatment regimens for RAO are scarce. We now determined whether the addition of antithrombotic to antiplatelet therapy improves the rate of partial or complete regain of patency in RAO following transradial cardiac catheterization in a retrospective analysis. Patients and methods : In a two-center tertiary referral hospital retrospective analysis 4135 files of patients who had undergone transradial catheterization were screened for documented RAO. 141 patients were identified and 138 patients with complete information on the medical regimen and ultrasound examinations for a maximum of 3 months were included in the analysis, whereas 3 patients were excluded due to missing or incomplete follow-up information. Results : 3.3% of all patients that had undergone transradial catheterization featured an oligosymptomatic RAO, confirmed by color-coded duplex sonography. 21% of patients with additional anticoagulation regained full patency vs. 9% without additional anticoagulation (p = 0.07). 40% of patients with anticoagulation featured a partial or full regain of patency vs. 16% of patients without additional anticoagulation for a maximum of 3 months treatment (p = 0.006). No major bleedings were reported during the follow-up visits. Conclusions : RAO remains a rare complication of cardiac catheterization. The addition of antithrombotic therapy for 3 months appears to safely improve the partial or even full regain of radial patency in case of postinterventional RAO.

Background Cardiovascular magnetic resonance imaging is considered the reference methodology for cardiac morphology and function but requires manual postprocessing. Whether novel artificial intelligence-based automated analyses deliver similar information for risk stratification is unknown. Therefore, this study aimed to investigate feasibility and prognostic implications of artificial intelligence-based, commercially available software analyses. Methods and Results Cardiovascular magnetic resonance data (n=1017 patients) from 2 myocardial infarction multicenter trials were included. Analyses of biventricular parameters including ejection fraction (EF) were manually and automatically assessed using conventional and artificial intelligence-based software. Obtained parameters entered regression analyses for prediction of major adverse cardiac events, defined as death, reinfarction, or congestive heart failure, within 1 year after the acute event. Both manual and uncorrected automated volumetric assessments showed similar impact on outcome in univariate analyses (left ventricular EF, manual: hazard ratio [HR], 0.93 [95% CI 0.91-0.95]; P <0.001; automated: HR, 0.94 [95% CI, 0.92-0.96]; P <0.001) and multivariable analyses (left ventricular EF, manual: HR, 0.95 [95% CI, 0.92-0.98]; P =0.001; automated: HR, 0.95 [95% CI, 0.92-0.98]; P =0.001). Manual correction of the automated contours did not lead to improved risk prediction (left ventricular EF, area under the curve: 0.67 automated versus 0.68 automated corrected; P =0.49). There was acceptable agreement (left ventricular EF: bias, 2.6%; 95% limits of agreement, -9.1% to 14.2%; intraclass correlation coefficient, 0.88 [95% CI, 0.77-0.93]) of manual and automated volumetric assessments. Conclusions User-independent volumetric analyses performed by fully automated software are feasible, and results are equally predictive of major adverse cardiac events compared with conventional analyses in patients following myocardial infarction. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT00712101 and NCT01612312.

Objective: Surgery is an effective but costly treatment for many patients with drug-resistant temporal lobe epilepsy (DR-TLE). We aim to evaluate whether, in the United States, surgery is cost-effective compared to medical management for patients deemed surgical candidates and whether surgical evaluation is cost-effective for patients with DR-TLE in general., Methods: We use a semi-Markov model to assess the cost-effectiveness of surgery and surgical evaluation over a lifetime horizon. We use second-order Monte Carlo simulations to conduct probabilistic sensitivity analyses to estimate variation in model output. We adopt both health care and societal perspectives, including direct health care costs (e.g., surgery, antiepileptic drugs) and indirect costs (e.g., lost earnings by patients and care providers.) We compare the incremental cost-effectiveness ratio to societal willingness to pay (∼$100,000 per quality-adjusted life-year [QALY]) to determine whether surgery is cost-effective., Results: Epilepsy surgery is cost-effective compared to medical management in surgically eligible patients by virtue of being cost-saving ($328,000 vs $423,000) and more effective (16.6 vs 13.6 QALY) than medical management in the long run. Surgical evaluation is cost-effective in patients with DR-TLE even if the probability of being deemed a surgical candidate is only 5%. From a societal perspective, surgery becomes cost-effective within 3 years, and 89% of simulations favor surgery over the lifetime horizon., Conclusion: For surgically eligible patients with DR-TLE, surgery is cost-effective. For patients with DR-TLE in general, referral for surgical evaluation (and possible subsequent surgery) is cost-effective. Patients with DR-TLE should be referred for surgical evaluation without hesitation on cost-effectiveness grounds., (© 2020 American Academy of Neurology.)