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Virtual surgical planning (VSP) for composite microvascular free flaps has become standard of care for oncologic head and neck reconstruction. Controversy remains as to the use of three-dimensional (3D)-printed patient-specific titanium implants (PSIs) versus hand-bent stock reconstruction plates. Proponents of PSIs cite improved surgical accuracy, reduced operative times, and improved clinical outcomes. Detractors purport increased cost associated with PSIs and presumed equivalent accuracy with less expensive stock plates. The study purpose was to measure and compare the 3D-volumetric accuracy of PSI versus stock reconstruction plates among subjects undergoing VSP-guided mandibular fibular free flap reconstruction. A retrospective cohort study of subjects undergoing VSP-guided fibular free flap reconstructions at Mayo Clinic between 2016 and 2023 was performed. Subjects were excluded for non-VSP guidance, midfacial reconstruction, nonfibular free flaps, and lack of requisite study variables. The primary predictor was the type of reconstruction plate utilized (PSI vs stock plate). The main outcome was volumetric surgical accuracy of the final reconstruction compared to the preoperative surgical plan by root mean square error (RMSE) calculation. Lower RMSE values indicated a higher surgical accuracy. Covariates included age, sex, race, smoking status, American Society of Anesthesiologists (ASA) Physical Status Classification System, Charlson Comorbidity Index, preoperative diagnosis, and number of fibular segments. Differences in surgical accuracy were assessed between preoperative and postoperative segmented scans using volumetric overlays from which RMSE values were calculated. Univariate and multivariate modeling of plate type to RMSE calculation was performed. Statistical significance set to P <.05. Total of 130 subjects were identified, 105 PSI and 25 stock plates. Calculated mean RMSE in millimeters (mm) for stock plates was 1.46 (standard deviation: 0.33) and 1.15 (standard deviation: 0.36) for PSIs. Univariate modeling demonstrated a statistically significant difference in RMSE of 0.31 (95% confidence interval: 0.16-0.47) (P <.001) equating to a 21.2% (P <.001) improved volumetric surgical accuracy for PSIs. The association of improved volumetric accuracy with PSIs has been maintained in all multivariate models controlling for confounding. In modern era VSP-guided head and neck fibular free flap reconstruction, patient-specific 3D-printed titanium implants confer a statistically significant improvement in volumetric surgical accuracy over stock reconstruction plates. [ABSTRACT FROM AUTHOR]

The objective of this study was to retrospectively review clinical and radiographic outcomes of patients who underwent corrective osteotomies for clavicle malunion and internal fixation for nonunion using a combination of virtual surgical planning, patient-specific 3-dimensional (3D)–printed clavicles, and 3D-printed cutting guides manufactured at the point of care. Between 2015 and 2021, 18 patients underwent corrective osteotomy for a clavicle malunion (7 shoulders) or internal fixation for a clavicle nonunion (11 shoulders). There were 11 male and 7 female individuals with an average patient age of 43.9 (range 19-76) years. All patients underwent computed tomography evaluation of both clavicles. The DICOM files were manually segmented, virtual surgical planning was performed selectively using commercially available software, and a mirrored version of the normal clavicle was 3D printed along with a 3D-printed replica of the affected clavicle. Three-dimensionally printed mirrored clavicles were used in all cases to ensure adequate restoration of the shape and length of the clavicle and to precontour fixation plates. Virtual surgical planning and 3D-printed cutting guides for osteotomy were used in 4 of 18 (22%) patients. Either cancellous or structural intercalary bone grafting was used in 15 of 18 (83%) cases. Patients were contacted postoperatively to determine clinical outcome scores. Preoperative, early postoperative, and late postoperative radiographs were reviewed to assess for union and complications. The average follow-up time was 24.9 months. Radiographic evaluation at the most recent follow-up demonstrated adequate restoration of length and successful union for all shoulders. There were no complications or reoperations. Postoperative patient-reported outcomes could be obtained in 16 of 18 (88.9%) patients. At the most recent follow-up, the mean visual analog scale for pain was 2.38 points (range, 1-7), the mean shoulder American Shoulder and Elbow Surgeons score was 73.2 points (range, 25-100), and the mean Patient-Reported Outcome Measurement Information System Upper Extremity score was 26 points (range, 7-35). All (100%) the patients were satisfied with their outcome (9 very satisfied, 7 satisfied), and their mean subjective shoulder value was 73% (range, 10%-100%). However, 2 patients complained of hardware-related symptoms, and 1 patient had return of preoperative symptoms after an interim 2 years of pain relief. The use of mirrored 3D-printed clavicles combined with virtual surgical planning and patient-specific 3D guides provides a reliable technique for restoring native anatomy when performing corrective osteotomies for clavicle malunion or internal fixation for clavicle nonunion, with a high rate of satisfactory clinical and radiographic outcomes. [ABSTRACT FROM AUTHOR]

Trochlear dysplasia is a major contributor to patellofemoral instability and subsequent failure of isolated soft tissue reconstruction procedures in the treatment of recurrent patellar dislocation and/or subluxation. Trochleoplasty procedures aim to address abnormal osseous trochlear morphologic factors that contribute to patellar maltracking. However, teaching these techniques is limited by the lack of reliable training models for trochlear dysplasia and trochleoplasty simulation. Although a cadaveric knee model of trochlear dysplasia for trochleoplasty simulation has been recently described, cadaveric knees are less amenable for use in trochleoplasty planning and surgeon training because of the absence of reliable, natural dysplastic anatomic relationships, such as suprapatellar spurs due to the rarity of dysplastic cadavers and the high cost of cadaveric specimens. Furthermore, readily available sawbone models represent "normal" osseous trochlear morphology and are difficult to modify and bend due to their material composition. Given this, we have developed a cost-effective, reliable, and anatomically accurate three-dimensional (3D) knee model of trochlear dysplasia for trochleoplasty simulation and trainee education. [Display omitted] [ABSTRACT FROM AUTHOR]

There is a paucity of utility and cost data regarding the launch of 3D printing in a hospital. The objective of this project is to benchmark utility and costs for radiology-based in-hospital 3D printing of anatomic models in a single, adult academic hospital. All consecutive patients for whom 3D printed anatomic models were requested during the first year of operation were included. All 3D printing activities were documented by the 3D printing faculty and referring specialists. For patients who underwent a procedure informed by 3D printing, clinical utility was determined by the specialist who requested the model. A new metric for utility termed Anatomic Model Utility Points with range 0 (lowest utility) to 500 (highest utility) was derived from the specialist answers to Likert statements. Costs expressed in United States dollars were tallied from all 3D printing human resources and overhead. Total costs, focused costs, and outsourced costs were estimated. The specialist estimated the procedure room time saved from the 3D printed model. The time saved was converted to dollars using hospital procedure room costs. The 78 patients referred for 3D printed anatomic models included 11 clinical indications. For the 68 patients who had a procedure, the anatomic model utility points had an overall mean (SD) of 312 (57) per patient (range, 200-450 points). The total operation cost was $213,450. The total cost, focused costs, and outsourced costs were $2,737, $2,180, and $2,467 per model, respectively. Estimated procedure time saved had a mean (SD) of 29.9 (12.1) min (range, 0-60 min). The hospital procedure room cost per minute was $97 (theoretical $2,900 per patient saved with model). Utility and cost benchmarks for anatomic models 3D printed in a hospital can inform health care budgets. Realizing pecuniary benefit from the procedure time saved requires future research. [ABSTRACT FROM AUTHOR]

Primary pulmonary artery sarcomas are rare tumors and are commonly misdiagnosed as pulmonary embolism. Primary pulmonary sarcomas demonstrate intraluminal growth into the vessel, rather than through the wall; require complete resection to enhance survival; and require complex surgical planning. The purpose of this case report is to describe an optimal team approach with multidisciplinary planning facilitated by a customized 3-dimensional model to guide intervention and enhance communication. [ABSTRACT FROM AUTHOR]

Background: Virtual surgical planning (VSP), computer aided design/computer aided modeling, and 3-dimensional printing technology have been shown to improve surgical accuracy and efficiency in head and neck reconstruction. However, persisting criticism of the technology is that it does not adequately address the soft tissue-related aspects of reconstructive surgery. Prior publication on the computed tomographic angiography (CTA) perforator localization technique has demonstrated how soft tissue planning can be incorporated directly into existing VSP workflows.Purpose: The aim of this study is to prospectively assess the accuracy, precision, negative predictive value (NPV), and positive predictive value (PPV) of the CTA perforator localization technique for VSP of osteocutaneous fibular free flaps.Materials and Methods: A prospective observational study in a consecutive cohort of subjects undergoing VSP of osteocutaneous fibular free flaps at Mayo Clinic between 2018 and 2020 was completed. All cutaneous perforators from the peroneal system of the selected donor leg were identified preoperatively through a previously reported CTA tracing method and registered into the VSP. Perforators were classified as primary or secondary based on whether the perforators were targeted for use in the final reconstructive plan. Perforator measurements obtained from the VSP were cross-referenced with intraoperatively obtained measurements of actual perforator locations to calculate accuracy, precision, NPV, PPV, sensitivity, and specificity of the CTA localization technique.Results: Sixty consecutive subjects were enrolled in the study. A total of 141 perforators were identified preoperatively on CTA and 145 perforators were identified on operative exposure. One perforator identified on preoperative CTA was not identified on surgical exposure (false positive perforator). Six perforators were identified on operative exposure alone without recognition on preoperative CTA (false negative perforators). The accuracy of CTA perforator identification was 96.52%. Median precision of perforator localization was 0.3 cm (standard deviation 0.40) between CTA and operatively identified locations. PPV of the technique was 99.29% and NPV was 90.00%.Conclusion: The CTA localization technique for identifying and incorporating cutaneous perforator locations into VSP of osteocutaneous fibular free flaps is a reliable, accurate, and precise technique to employ in the modern paradigm of guided surgery for head and neck reconstruction. [ABSTRACT FROM AUTHOR]

Pain flares are a common acute toxic effect after stereotactic body radiation therapy (SBRT) for spine metastasis. We aimed to identify a subset of patients with the highest rate of pain flare after spine SBRT to optimize prophylactic corticosteroid administration. The data set included 428 patients with 610 treatments. We defined pain flare as acute worsening of pain at the treatment site requiring new or higher dose therapy with corticosteroids, opiates, and/or hospitalization. Data were split into 70% training and 30% validation sets using a random number generator. After feature importance testing and generation of a correlation heatmap, feature extraction was performed via recursive partitioning analysis. We identified 125 total pain flares (20%). Five variables met significance (P <.02) for model inclusion: renal primary, soft tissue involvement, Bilsky >0, spinal instability neoplastic score >6, and gross tumor volume >8 cc. One point was assigned for each variable. The low-risk group (score = 0, n = 159) had pain flare rates of 7.0% and 13.6% in the training and validation sets; the intermediate-risk group (score = 1, n = 150) had rates of 14.0% and 16.3%; and the high-risk group (score >1, n = 301) had rates of 28.8% and 31.3%. Patients in the high-risk group had higher rates of flare (odds ratio, 3.50; 95% confidence interval, 2.06-5.92) and accumulated health care costs 3 and 6 months post-SBRT, relative to intermediate- and low-risk patients (P <.001). Our internally validated model identifies a high-risk group of patients more likely to develop a pain flare after spine SBRT, for whom prophylactic steroids may be considered. Evaluation in a clinical trial is warranted. [ABSTRACT FROM AUTHOR]

Clival chordomas are classically thought of as locally aggressive tumors of the skull base and differentiate themselves from their benign counterparts by demonstrating moderate to marked contrast enhancement, reported as 95–100% in prior studies. The purpose of this review was to evaluate the imaging characteristics of lesions from a single institution classified as clival chordomas with an emphasis of highlighting lesions that do not follow the prevalent current description for chordoma. We searched our institutional databases for all patients with pathologically proven clival chordomas from 1997 to 2017 who had pre-operative imaging available. The images were evaluated for degree of contrast enhancement, MRI signal characteristics, osseous involvement, location, aggressiveness of appearance, and presence of calcifications. 28 cases were identified that had preoperative imaging available for review. Over half of the patients demonstrated either no/minimal (11/28, 39%) or mild enhancement (7/28, 25%). The remaining cases demonstrated moderate (4/28, 14%) and marked enhancement (6/28, 21%). The 4 lesions measuring less than 20 mm all had mild to minimal/no enhancement and lacked aggressive features on CT. Our experience finds that over half (64%) of clival chordomas will demonstrate mild or no enhancement at all. These findings suggest that the lack of MRI contrast enhancement should not be synonymous with a benign clival mass. [ABSTRACT FROM AUTHOR]

We analyzed the cost-effectiveness of standard palliative external beam radiation (EBRT, 8 Gy in 1 fraction), stereotactic body radiation therapy (SBRT, 24 Gy in 2 fractions), and radiofrequency ablation for painful spinal metastases. Single-fraction SBRT (delivering 24 Gy) was also assessed. A Markov state transition model was constructed. Key model parameters were derived from prospective clinical trial data. Strategies were compared using the incremental cost-effectiveness ratio (ICER), with effectiveness in quality-adjusted life-years (QALYs) and a willingness-to-pay threshold of $100,000 per QALY gained. Costs included both hospital and professional costs using 2020 Medicare reimbursement. The base case demonstrated that 2-fraction SBRT was not cost-effective compared with single-fraction EBRT, with an ICER of $194,145 per QALY gained. Radiofrequency ablation was a more costly and less effective strategy in this model. Probabilistic sensitivity analysis demonstrated that EBRT was favored in 66% of model iterations. If median survival were improved after SBRT, 2-fraction SBRT became cost-effective, with ICERs of $80,394, $57,062, and $47,038 for 3-, 6-, and 9-month improvements in survival, respectively. Because 2-fraction SBRT data reported that 18% of patients had an indeterminant pain response at 3 months and 2-fraction SBRT is infrequently used in clinical practice, single-fraction SBRT data were also assessed. Single-fraction SBRT delivering 24 Gy was cost-effective compared with single-fraction EBRT, with an ICER of $92,833 per QALY gained. For appropriately chosen patients, single-fraction SBRT was more cost-effective than conventional EBRT or radiofrequency ablation. Conventional EBRT remains a cost-effective treatment for patients with poor expected survival. [ABSTRACT FROM AUTHOR]

A 54-year-old man with a history of type 2 diabetes presented in 2020 for a Bentall procedure after undergoing cardiac surgery complicated by sternal osteomyelitis in 2011. Sternal closure after aortic root replacement included a laparoscopically harvested omental flap to cover the heart. In 2021, multidisciplinary complex sternal reconstruction using a customized 3-dimensional–printed implant based on the patient's computed tomography imaging was performed with compassionate use permission from the Food and Drug Administration. We report the successful entire sternal replacement using a synthetic polyethylene implant. [ABSTRACT FROM AUTHOR]

• T2 hypointensity may be a predictor of indolence in SFT/hemangiopericytomas. • T2 hypointense spinal lesions are rare, encompassing an array of diseases. • Review identified T2 hypointensity in 16 focal, 5 diffuse, and 4 mixed lesions. Spinal solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare mesenchymal malignancy. Radiographically, SFT/HPCs have a mutable appearance, with irregular borders, heterogeneous contrast enhancement, and variable but frequently hypointense T2 signal. We report a series of 5 neurosurgically managed spinal SFT/HPCs treated at our institution, with particular attention to 3 lesions demonstrating marked T2-hypointensity and differential diagnosis for the unusual finding of a "T2 dark" spinal lesion. Retrospective chart review of prospectively maintained surgical database, queried by diagnosis and site codes, 2002–2017. Retrospective radiographic review, with initial screening via keyword search of MR reports for "T2" and "hypointense." Four primary and one metastatic spinal SFT/HPCs were operatively treated during the study period (median follow-up 12 months; range 10–92). Three demonstrated marked T2 hypointensity on preoperative MRI, underwent primary resection—GTR in two, STR in one—and have remained progression-free on routine postoperative surveillance. Two patients with isointense lesions recurred within the follow-up period. Radiographic review identified a host of predominantly rare T2-hypointense lesions, including arteriovenous malformation, disk fragmentations, calcific arachnoiditis, calcifying pseudoneoplasm of the neuraxis, cavernoma, cord hemorrhage/acute blood, desmoid, granulocytic sarcoma, pigmented villonodular synovitis, Edheim-Chester, extramedullary hematopoiesis, IgG4-negative inflammatory pseudotumor, idiopathic hypertrophic pachymeningitis, B-cell lymphoma, primary melanoma neoplasm, melanotic schwannoma, meningioma, opacification of the posterior longitudinal ligament, osteoblastoma, osteochondroma, osteosarcoma, and synovial cyst. T2 hypointensity is associated with SFT/HPC, and may be an indicator relative indolence. "Dark" T2 spinal lesions are rare, with a narrow differential populated predominantly by rare entities. [ABSTRACT FROM AUTHOR]

Subscapular-based flaps have historically maintained an unparalleled ability to provide a multitude of bone and soft tissue components based on a single vascular pedicle. However, these flaps are often not thought of as an ideal choice for composite defects requiring extended lengths of bone for reconstruction. The ability to harvest long segments of bone and reliably perform multiple contouring osteotomies is fundamental to long-span composite mandibular reconstruction, and microvascular surgeons are often met with significant reconstructive challenges when fibular free flaps cannot be used owing to variant vascular anatomy or occlusive atherosclerotic disease in these specific clinical scenarios. This challenge is further compounded by treatment-related vessel depletion in the neck, which reduces the availability of suitable recipient vessels in close proximity to the reconstruction. We present a case in which all of the aforementioned challenges presented in a single individual, who concomitantly required hemimandibular reconstruction with treatment related vessel depletion in the neck and unsuitable bilateral vascular anatomy in the legs precluding the use of a fibular free flap. This case demonstrates a previously unreported flap component geometry for hemimandibular reconstruction using an extended-length chimeric scapular free flap with scapular tip, lateral scapular border, and parascapular fasciocutaneous skin paddle components. [ABSTRACT FROM AUTHOR]

In photosynthesis, solar energy is absorbed and converted into chemical energy. Chlorophyll embedded in proteins absorb light and transfer excitation energy to reaction centers where charge separation occurs. However, the solar flux incident on photosynthetic organisms is highly variable, requiring complex feedback systems to regulate the excitation pressure on reaction centers and prevent excess absorbed energy from causing damage. During periods of transient high light, excess absorbed energy is dissipated as heat. This is routinely observed as the quenching of chlorophyll fluorescence, and often broadly referred to as non-photochemical quenching (NPQ). Understanding the mechanisms through which photosynthetic systems dissipate excess energy and regulate excitation pressure in response to variable light conditions requires extensive quantitative modeling of the photosynthetic system and energy dissipation to interpret experimental observations. This review discusses efforts to model energy dissipation, or quenching, in Arabidopsis thaliana and their connections to models of regulatory systems that control quenching. We begin with a review of theory used to describe energy transfer and experimental data obtained to construct energy transfer models of the photosynthetic antenna system that underlie the interpretation of chlorophyll fluorescence quenching. Second, experimental evidence leading to proposed molecular mechanisms of quenching and the implications for modeling are discussed. The initial incorporation of depictions of proposed mechanisms into quantitative energy transfer models is reviewed. Finally, the necessity of connecting energy transfer models that include molecular models of quenching mechanisms with regulatory models is discussed. [ABSTRACT FROM AUTHOR]

Introduction: Currently there are no clinical screening tests available to identify pregnancies at risk of developing preeclampsia (PET) and/or intrauterine growth restriction (IUGR), both of which are associated with abnormal placentation. Metabolic profiling is now a stable analytical platform used in many laboratories and has successfully been used to identify biomarkers associated with various pathological states.Methods: We used nuclear magnetic resonance spectroscopy (NMR) to metabolically profile serum samples collected from 143 pregnant women at 26-41 weeks gestation with pregnancy outcomes of PET, IUGR, PET IUGR or small for gestational age (SGA) that were age-matched to normal pre/term pregnancies.Results: Spectral analysis found no difference in the measured metabolites from normal term, pre-term and SGA samples, and of 25 identified metabolites, only glutamate was marginally different between groups. Of the identified metabolites, 3-methylhistidine, creatinine, acetyl groups and acetate, were determined to be independent predictors of PET and produced area under the curves (AUC) = 0.938 and 0.936 for the discovery and validation sets. Only 3-hydroxybutyrate was determined to be an independent predictor of IUGR, however the model had low predictive power (AUC = 0.623 and 0.581 for the discovery and validation sets).Conclusions: A sub-panel of metabolites had strong predictive power for identifying PET samples in a validation dataset, however prediction of IUGR was more difficult using the identified metabolites. NMR based metabolomics can identify metabolites strongly associated with disease and has the potential to be useful in developing early clinical screening tests for at risk pregnancies. [ABSTRACT FROM AUTHOR]

Introduction Plasmacytomas, considered to be the solitary counterparts of multiple myeloma, are neoplastic monoclonal plasma cell proliferations within soft tissue or bone. Plasmacytomas often present as a collection of findings known as POEMS-syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, M-Protein spike, and Skin changes). Case description We present a report of a 47 yo male diagnosed with POEMS-syndrome secondary to a skull base plasmacytoma. The mass resulted in marked instability of the cranio-cervical junction due to bony erosion. Following an induction course of chemotherapy, he showed clinical improvement with a marked reduction in tumor size and underwent an autologous peripheral blood stem cell transplant for systemic treatment of his POEMS-syndrome. Following completion of systemic treatment, he then underwent a definitive occipital-cervical fusion without complications. His neurologic exam upon dismissal was stable with subjective improvement in left upper extremity strength. Postoperative radiographs confirmed spinal alignment and pathological examination of a small biopsy from C1 revealed benign fibrous tissue. Conclusion To the best of our knowledge, this is the first report of a skull-base plasmacytoma associated with POEMS-syndrome, causing cranio-cervical instability. The approach of systemic therapy combined with temporary external fixation, followed by definitive occipital cervical fusion resulted in a good outcome for this patient. [ABSTRACT FROM AUTHOR]

Purpose: To retrospectively review and report the efficacy and safety of percutaneous image-guided ablation (cryoablation or radiofrequency ablation) in the treatment of oligometastatic prostate cancer.Materials and Methods: An institutional registry was retrospectively reviewed and revealed 16 patients with oligometastatic prostate cancer (median age, 67 y; range, 50-86 y) who underwent percutaneous image-guided ablation to treat 18 metastatic sites. A subgroup of 7 patients with 8 metastases were androgen-deprivation therapy (ADT)-naïve and underwent ablation to delay initiation of ADT. Local tumor control, progression-free survival (PFS), ADT-free survival, and procedural complications were analyzed.Results: Local tumor control was achieved in 15 of 18 metastases (83%) at a median follow-up of 27 months (range, 5-56 mo). Local tumor recurrence was found in 3 of 18 metastases (17%), with a median time to local recurrence of 3.5 months (range, 3-38 mo). Estimated PFS rates at 12 and 24 months were 56% (95% confidence interval [CI], 30%-76%) and 43% (95% CI, 19%-65%), respectively. In the 7 ADT-naïve patients, local tumor control was achieved in all metastases, and the median ADT-free survival period was 29 months. There were no major procedural complications.Conclusions: In this cohort of patients with oligometastatic prostate cancer, percutaneous image-guided ablation was feasible and well tolerated and achieved acceptable local tumor control rates. Percutaneous ablation may be of particular utility in patients who wish to delay initiation of ADT. [ABSTRACT FROM AUTHOR]

Purpose To describe the feasibility, safety, and effectiveness of a technique using vertebral augmentation balloons to promote delivery of cement into periacetabular tumors after cryoablation for fracture prevention. Materials and Methods A retrospective review was performed of seven consecutive patients (six men and one woman; mean age, 64 y ± 8) with unilateral periacetabular tumors (mean size, 4.2 cm ± 1.4) treated with cryoablation and balloon-assisted osteoplasty for fracture prevention. Cortical defects were seen in six (86%) tumors, and additional pathologic fractures occurred in five (71%) tumors before treatment. The cohort included six (86%) Harrington class I defects and one (14%) class II defect. Procedures were performed with computed tomography fluoroscopic guidance and general anesthesia. Vertebral augmentation balloons (mean, 2; range, 1–4) were inflated within the ablation cavity immediately before or during cement injection. Results All procedures were technically successful. Median percentage tumor fill was 63% (range, 17%–96%). Minor cement leakage occurred in two (29%) patients with no symptomatic or intraarticular extravasation. A new nondisplaced fracture occurred in one patient and was conservatively managed. No major complications occurred. Local tumor progression occurred in one (20%) of five patients with imaging follow-up. Conclusions Balloon-assisted osteoplasty after cryoablation of periacetabular tumors appears feasible, safe, and effective for fracture prevention. This technique directs cement instillation into ablation defects with a high degree of filling and minimal leakage. [ABSTRACT FROM AUTHOR]

Objective: to gain an understanding of how women conceptualise continuity of maternity care. Design: a qualitative study involving in-depth semi-structured interviews and thematic analysis. Setting: a range of urban and rural public hospitals in New South Wales, Australia. Participants: 53 women aged 18-44 years (median age 27 years) receiving maternity care in 2011-2012. Findings: responses from women suggested five concepts of continuity: continuity of staff, continuity of relationship, continuity of information, continuity across pregnancies and continuity across locations. These concepts of continuity differed by parity and location. Conclusion and implications for practice: continuity of maternity care has a variety of meanings to women. If health care providers are to commit to providing woman-centred maternity care it is important to recognise the diversity of women's experiences, and ensure that systems of care are flexible and appropriate to women's circumstances and needs. [ABSTRACT FROM AUTHOR]

Purpose To describe the use of intraprocedural motor evoked potential (MEP) monitoring to minimize risk of neural injury during percutaneous cryoablation of perineural musculoskeletal tumors. Materials and Methods A single-institution retrospective review of cryoablation procedures performed to treat perineural musculoskeletal tumors with the use of MEP monitoring between May 2011 and March 2013 yielded 59 procedures to treat 64 tumors in 52 patients (26 male). Median age was 61 years (range, 4–82 y). Tumors were located in the spine (n = 27), sacrum (n = 3), retroperitoneum (n = 4), pelvis (n = 22), and extremities (n = 8), and 21 different tumor histologies were represented. Median tumor size was 4.0 cm (range, 0.8–15.0 cm). Total intravenous general anesthesia, computed tomographic guidance, and transcranial MEP monitoring were employed. Patient demographics, tumor characteristics, MEP findings, and clinical outcomes were assessed. Results Nineteen of 59 procedures (32%) resulted in decreases in intraprocedural MEPs, including 15 (25%) with transient decreases and four (7%) with persistent decreases. Two of the four patients with persistent MEP decreases (50%) had motor deficits following ablation. No functional motor deficit developed in a patient with transient MEP decreases or no MEP change. The risk of major motor injury with persistent MEP changes was significantly increased versus transient or no MEP change ( P = .0045; relative risk, 69.8; 95% confidence interval, 5.9 to > 100). MEP decreases were 100% sensitive and 70% specific for the detection of motor deficits. Conclusions Persistent MEP decreases correlate with postprocedural sustained motor deficits. Intraprocedural MEP monitoring helps predict neural injury and may improve patient safety during cryoablation of perineural musculoskeletal tumors. [ABSTRACT FROM AUTHOR]

The selection and maturation of B-cell clones are critically determined by tonic signals from activated B cell receptors (BCR) and survival signals from BAFF cytokine. These finely tuned and coordinated signals provide a net positive signal that can promote the selection, maturation, proliferation and differentiation of a developing B cell. Stimulation with an anti-IgD antibody can also activate BCR but can lead to depletion and an arrest of mature B-cell development in vivo. It is not known whether survival signals from excess BAFF can override the suppressive effects of treatment with anti-IgD on mature B cells in vivo. Herein, we examined the effects of co-treatment of BAFF and anti-IgD on the mature B-cell compartment and antibody production in vivo by treating mice with either 1 mg/kg BAFF or anti-IgD alone or in combination for 3 consecutive days. We found that co-treatment with anti-IgD significantly abrogated these stimulatory effects of BAFF treatment on splenic CD19+ B cells as well as mature CD19+IgDhiIgM+ B cells in vivo. Anti-IgD down-regulated the expression of the BCR complex (mIgM, mIgD and CD19) and the BAFF receptor TACI without regard to the presence of BAFF. Anti-IgD treatment also significantly negated BAFF-induced IgM production in vivo. Both BAFF and anti-IgD could individually stimulate IL-10 synthesis in B cells but did not affect one another. Taken together, our data suggest that activation of BCR with an anti-IgD antibody can override the stimulatory effects from excess BAFF on B cell proliferation and antibody production by down-regulating the expression of BCR complex and BAFF receptors. [ABSTRACT FROM AUTHOR]

Background Although surveys have identified that women are generally highly satisfied with maternity care provision, those aspects of care that women highlight as most important for achieving satisfaction and a satisfactory maternity care experience have not been reported. The aim of this study was to investigate how women understand and experience their maternity care and to report which aspects of care women highlight as most important. Methods This large qualitative study explored women's expectations and experiences of maternity care provision. In-depth semi-structured interviews were conducted with 53 women experiencing maternity care in a range of tertiary, regional, rural, remote hospitals and midwife-led practices in the state of New South Wales, Australia during 2011-2012. Included in the interview schedule was the question 'What 3 aspects would you see as most important for delivery of maternity care?' Descriptive analyses of entire transcripts and responses to the question on most important aspects of care were undertaken. Results Descriptive analyses of women's responses identified 5 important aspects of care: woman-focused care, staff qualities, systems and facilities, family-focused care and continuity of care/information. First-time mothers were more likely to identify woman-focused care, staff qualities and continuity of care/information as important aspects than multiparous mothers. Urban and regional mothers highlighted staff qualities as having greater importance for satisfaction with their care while rural and particularly remote women nominated systems and facilities as important. Conclusions Our study showed that women from a range of settings are more concerned with staff and relational issues than facilities. Differences in perceptions among primiparous versus multiparous women, at different stages of pregnancy and among women from rural and remote compared to urban settings highlight the need to include women with a diversity of experience when trying to understand the aspects of maternity care most important to women. [ABSTRACT FROM AUTHOR]

Background: Low serum 25-hydroxyvitamin D [25(OH)D] concentrations during pregnancy have been associated with adverse pregnancy outcomes in a few studies but not in other studies. Objectives: We assessed the serum 25(OH)D concentration at 10-14 wk of pregnancy and its association with adverse pregnancy outcomes and examined the predictive accuracy. Design: In this nested case-control study, we measured serum 25(OH)D in 5109 women with singleton pregnancies who were attending first-trimester screening in New South Wales, Australia. Multivariate logistic regression was conducted to examine the association between low 25(OH)D concentrations and adverse pregnancy outcomes (small for gestational age, preterm birth, preeclampsia, gestational diabetes, miscarriage, and stillbirth). The predictive accuracy of models was assessed. Results: The median (IQR) 25(OH)D concentration for the total population was 56.4 nmol/L (43.3-69.8 nmol/L). Serum 25(OH)D concentrations showed significant variation by parity, smoking, weight, season of sampling, country of birth, and socioeconomic status. After adjustment for maternal and clinical risk factors, low 25(OH)D concentrations were not associated with most adverse pregnancy outcomes. The area under the receiver operating characteristic curve (AUC) and likelihood ratio for a composite of severe adverse pregnancy outcomes of 25(OH)D concentrations <25 nmol/L were 0.51 and 1.44, respectively, and, for risk factors alone, were 0.64 and 2.87, respectively. The addition of 25(OH)D information to maternal and clinical risk factors did not improve the ability to predict severe adverse pregnancy outcomes (AUC: 0.64; likelihood ratio: 2.32; P = 0.39). Conclusion: Low 25(OH)D serum concentrations in the first trimester of pregnancy are not associated with adverse pregnancy outcomes and do not predict complications any better than routinely assessed clinical and maternal risk-factor information. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To assess the safety and effectiveness of percutaneous cryoablation to treat limited metastases to the musculoskeletal system, with the goal of complete disease remission. Materials and Methods: In a single-institution retrospective study of data from December 2003 to October 2011, 43 consecutive patients underwent initial cryoablation of limited (five or fewer) musculoskeletal metastases with the goal of complete disease remission (ie, no clinical or radiographic evidence of disease). Three patients were lost to follow-up. As a result, the present report describes 40 patients who underwent 40 cryoablation procedures to treat 52 tumors. Results: Local control was achieved in 45 of 52 tumors (87%; 95% confidence interval [CI], 75%–93%) at a median follow-up of 21 months (range, 4–62 mo). Thirteen of 19 treated bone metastases (68%) and 32 of 33 soft-tissue metastases (97%) showed local control (P = .007). One- and 2-year overall survival rates were 91% (95% CI, 75%–97%) and 84% (95% CI, 65%–93%), respectively. Median overall survival was 47 months (95% CI, 26–62 mo). One- and 2-year disease-free survival rates were 22% (95% CI, 11%–37%) and 7% (95% CI,<1% to 26%), respectively. Median disease-free survival was 7 months (95% CI, 5–10 mo). Two of 40 procedures (5%) were associated with major complications. Conclusions: Percutaneous cryoablation is a safe and effective treatment to achieve local tumor control and short-term complete disease remission in patients with limited metastatic disease to the musculoskeletal system. [Copyright &y& Elsevier]

Abstract: Purpose: To review the safety and efficacy of cryoablation of recurrent sacrococcygeal tumors. Materials and Methods: The radiology departmental ablation database was retrospectively searched for cases of cryoablation performed to treat recurrences of sacrococcygeal tumors between January 1, 2010, and August 1, 2011. Patient demographics, procedure technical parameters, and patient outcomes were reviewed. Results: Five cases of recurrent chordoma and one recurrent myxopapillary ependymoma were treated with cryoablation in six patients whose ages ranged from 31 to 80 years. The tumors measured 14–39 mm in maximal dimension. Cryoablation was performed with the use of computed tomography guidance (n = 5) or a combination of ultrasound and magnetic resonance imaging guidance (n = 1). Sterile fluid was instilled to displace adjacent bowel and/or vagina in four cases, and electromyography monitoring was performed in two cases with adjacent nerve roots. Two patients with recurrent chordoma were treated for palliation of pain, with complete pain relief in one patient (pain recurred after 6 wk) and immediate reduction in pain from a score of six to a score of two on a 10-point scale in the other (pain recurred after 7 mo). Four tumors were treated for local control, with no evidence of recurrence on follow-up imaging at 3, 6, 12, and 15 months. No serious complication occurred. Conclusions: Limited results suggest cryoablation to be a safe and relatively effective means of treating recurrent sacrococcygeal neoplasms for local control or palliation of pain in this small series with short-term follow-up. [Copyright &y& Elsevier]

Objective: To assess angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), and the Ang-1/Ang-2 ratio levels in the first trimester of pregnancy, their association with adverse pregnancy outcomes, and their predictive accuracy. Study Design: This cohort study measured serum Ang-1 and Ang-2 levels in 4785 women with singleton pregnancies attending first trimester screening in New South Wales, Australia. Multivariate logistic regression models were used to assess the association and predictive accuracy of serum biomarkers with subsequent adverse pregnancy outcomes (small for gestational age, preterm birth, preeclampsia, miscarriage >10 weeks, and stillbirth). Results: Median (interquartile range) levels for Ang-1, Ang-2, and the Ang-1/Ang-2 ratio for the total population were 19.6 ng/mL (13.6–26.4), 15.5 ng/mL (10.3–22.7), and 1.21 (0.83–1.73), respectively. Maternal age, weight, country of birth, and socioeconomic status significantly affected Ang-1, Ang-2, and the Ang-1/Ang-2 ratio levels. After adjusting for maternal and clinical risk factors, women with low Ang-2 levels (<10th percentile) and high Ang-1/Ang-2 ratio (>90th percentile) had increased risk of developing most adverse pregnancy outcomes. Compared with the Ang-1/Ang-2 ratio alone, maternal and clinical risk factors had better predictive accuracy for most adverse pregnancy outcomes. The exception was miscarriage (Ang-1/Ang-2 ratio area under receiver operating characteristic curve = 0.70; maternal risk factors = 0.58). Overall, adding the Ang-1/Ang-2 ratio to maternal risk factors did not improve the ability of the models to predict adverse pregnancy outcomes. Conclusion: Our findings suggest that the Ang-1/Ang-2 ratio in first trimester is associated with most adverse pregnancy outcomes, but do not predict outcomes any better than clinical and maternal risk factor information. [Copyright &y& Elsevier]

Abstract: Background context: An extraforaminal disc herniation may present as a retroperitoneal mass and is thus a differential diagnosis for a malignant lesion. Purpose: To highlight the difficulty in the accurate preoperative differentiation between an extraforaminal disc herniation and a malignant retroperitoneal mass despite the use of advanced anatomical and metabolic imaging. Study design: Case report. Methods: The authors present a case of a 55-year-old man, with a family history of neurofibromatosis, who presented to us 2 months after the insidious occurrence of severe, unrelenting, right-sided, L5 dermatomal pain. He subsequently developed rapidly progressive motor weakness in the same myotome, which caused a foot drop. On examination, his straight-leg raise test was normal. Magnetic resonance imaging demonstrated a peripherally enhancing, complex, cystic mass continuous with the L5 nerve, displacing its fascicles medially, as it descended over the right sacral ala. A positron emission tomography scan demonstrated increased radiotracer uptake. The clinicoradiologic presentation was that of a malignant peripheral nerve sheath tumor. Results: At surgery, an intraneural disc herniation was seen. Conclusions: Several pitfalls exist in establishing the uncommon diagnosis of an extraforaminal disc herniation. This entity occurs ventrally and must remain a consideration when elaborating the differential diagnosis of a retroperitoneal mass in close proximity to the vertebral column. [Copyright &y& Elsevier]

Objective: Late-preterm infants (34 weeks 0/7 days-36 weeks 6/7 days'' gestation) represent the largest proportion of singleton preterm births. A systematic review was performed to access the short- and/or long-term morbidity of late-preterm infants. Study Design: An electronic search was conducted for cohort studies published from January 2000 through July 2010. Results: We identified 22 studies studying 29,375,675 infants. Compared with infants born at term, infants born late preterm were more likely to suffer poorer short-term outcomes such as respiratory distress syndrome (relative risk [RR], 17.3), intraventricular hemorrhage (RR, 4.9), and death <28 days (RR, 5.9). Beyond the neonatal period, late-preterm infants were more likely to die in the first year (RR, 3.7) and to suffer from cerebral palsy (RR, 3.1). Conclusion: Although the absolute incidence of neonatal mortality and morbidity in infants born late preterm is low, its incidence is significantly increased as compared with infants born at term. [Copyright &y& Elsevier]

Objective: We undertook a systematic review to assess normative levels of vitamin D in early pregnancy and association with subsequent pregnancy outcomes. Study Design: Medline and Embase databases and reference lists were searched. Inclusion criteria were pregnant populations, blood sample taken during the first trimester, and serum hydroxyvitamin D levels assessed. Results: Eighteen studies reported vitamin D levels in first trimester (n = 11-3730), and 5 examined pregnancy outcomes. Mean vitamin D concentrations differed when stratified by ethnicity: white (mean [SD]: 29.4 [11.7] to 73.1 [27.1] nmol/L) and nonwhite (15.2 [12.1] to 43 [12] nmol/L). Most studies used general population cut points to define deficiency and found a large proportion of women deficient. Two articles examined risk of preeclampsia and reported differing findings, whereas 2 of 3 found low levels associated with increased risk of small-for-gestational age births. Conclusion: There is no clear definition of vitamin D deficiency in pregnancy and insufficient evidence to suggest low vitamin D levels in early pregnancy are associated with adverse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Background: The authors previously reported anterior decompression of C1-2 synovial cysts and subsequent posterior fusion in a large series. Although the surgical morbidity and mortality were acceptable, prior reports of stand-alone C1-2 fusion with resolution of cyst compression presumptively by correction of joint instability were intriguing and did not involve the morbidity associated with the transoral procedure. Methods: Three cases of retroodontoid cysts that resolved after posterior instrumentation and fusion are presented. These cysts were not associated with rheumatoid arthritis. An additional nine cases from the literature in which fusion was performed without cyst extirpation are reviewed. Results: Three patients presented with retroodontoid cysts. Two patients underwent posterior occipitocervical fusion with instrumentation alone. One patient underwent transoral decompression followed by occipitocervical fusion with instrumentation. In this one patient, magnetic resonance imaging performed early after the transoral procedure demonstrated substantial residual cyst. In all cases, follow-up magnetic resonance imaging performed 6–19 months later demonstrated near-complete resolution of the cysts. A literature review was done to find all other similar cases. Demographics, clinical presentation, imaging, and surgical outcome of these cases were analyzed. Conclusions: In asymptomatic patients with a synovial cyst of the atlantoaxial junction, posterior fusion alone may lead to complete resolution of the cyst; however, in neurologically symptomatic patients with similar lesions, cyst decompression coupled with posterior fusion is recommended to ensure the highest chance of cyst resolution and clinical improvement. [ABSTRACT FROM AUTHOR]

Abstract: Observations that the innate arm of the immune system is upregulated in pregnancy have highlighted the need for methods of isolating pure populations of monocytes for studies into pregnancy and pre-eclampsia without activating them during the isolation process. Density gradient centrifugation using iodixanol is a useful method for isolating relatively pure populations of unactivated monocytes from human blood but has not been validated in pregnant subjects. We compared the ability of monocytes isolated from pregnant women by density gradient centrifugation using iodixanol (n=6) with monocytes isolated by countercurrent centrifugal elutriation (n=6) in terms of their ability to produce interleukin-6 (IL-6) and monocyte chemoattractant protein-1 (MCP-1) under basal conditions and after stimulation with bacterial lipopolysaccharide (LPS). Under basal conditions, monocytes isolated by density gradient centrifugation produced low amounts of IL-6 and MCP-1. Production of IL-6 and MCP-1 after stimulation of the monocytes with LPS was much greater (p&#60;0.01). There was no statistically significant difference between the two methods in terms of stimulated levels of either cytokine. [Copyright &y& Elsevier]