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To evaluate whether there is a relationship between preoperative anemia and domain-specific cognitive performance in patients undergoing cardiac surgery.Retrospective analysis of data collected from a randomized study.Tertiary care university hospital.A total of 436 patients age ≥55 years undergoing cardiac surgery.None.Neuropsychological testing was performed before and one month after surgery, using a standard battery. Individual Z-scores calculated from the mean and standard deviation of tests at baseline were combined into domain-specific scores. Anemia (hemoglobin130 g/L for men,120 g/L for women) was present in 41% of patients. Preoperative anemia had little impact on preoperative cognition. There were no differences in the change in cognitive performance one month after surgery from baseline between patients with and without preoperative anemia. However, in a sensitivity analysis using multiple imputation for missing cognitive test scores, significant associations were observed between preoperative anemia and change in postoperative processing speed (p = 0.016), change in executive function (p = 0.049), and change in fine motor speed (p = 0.016). Nadir hemoglobin during cardiopulmonary bypass, which was lower in anemic than nonanemic patients, was associated with decrements in performance on tests of verbal fluency (p = 0.007), processing speed (p = 0.042), and executive function (p = 0.10) one month after surgery but not delayed neurocognitive recovery (p = 0.06).Preoperative anemia may be associated with impairment of selective cognitive domains after surgery. Any effect of preoperative anemia may have on cognition after surgery might be related to lower nadir hemoglobin during cardiopulmonary bypass.

Patients with advanced pyogenic spondylodiscitis can present with neurologic deficits. However, the prevalence, severity, and outcome of the neurologic deficits are not well known. A systematic review was performed to improve the knowledge of this commonly encountered clinical scenario. The considerable number of severe neurologic deficits in addition to their poor recovery, even after surgical intervention, demonstrates that the early diagnosis of pyogenic spondylodiscitis is crucial. Prompt surgical intervention is likely associated with a greater chance of improvement of neurologic status than nonsurgical treatment.

Objectives Berzosertib (formerly M6620, VX-970) is an intravenous, highly potent and selective, first-in-class ataxia telangiectasia and Rad3-related (ATR) protein kinase inhibitor. We assessed the safety, tolerability, preliminary efficacy, and pharmacokinetics (PK) of berzosertib plus gemcitabine in an expansion cohort of patients with advanced non–small cell lung cancer (NSCLC). The association of efficacy with TP53 status and other tumor markers was also explored. Materials and Methods Adult patients with advanced histologically confirmed NSCLC received berzosertib 210 mg/m2 (days 2 and 9) and gemcitabine 1000 mg/m2 (days 1 and 8) at the recommended phase 2 dose established in the dose escalation part of the study. Results Thirty-eight patients received at least one dose of study treatment. The most common treatment–emergent adverse events were fatigue (55.3%), anemia (52.6%), and nausea (39.5%). Gemcitabine had no apparent effect on the PK of berzosertib. The objective response rate (ORR) was 10.5% (4/38, 90% confidence interval [CI] 3.7–22.5). In the exploratory analysis, the ORR was 30.0% (3/10, CI: 9.0–61.0%) in patients with high loss of heterozygosity (LOH) and 11.0% (1/9, 90% CI: 1.0–43.0%) in patients with low LOH. The ORR was 33.0% (2/6, CI: 6.0–73.0%) in patients with high tumor mutational burden (TMB), 12.5% (2/16, 90% CI: 2.0–34.0%) in patients with intermediate TMB, and 0% (0/3, 90% CI: 0.0–53.6%) in patients with low TMB. Conclusions Berzosertib plus gemcitabine was well tolerated in patients with advanced, pre-treated NSCLC. Based on the observed clinical efficacy, future clinical trials should involve genomically selected patients.

Previous research has established an impact of acute exercise on cognitive performance, which has inspired investigations into neurobiological mechanisms that may underlie the observed benefits. Pupillary responses have been posited to reflect activation of such underlying neurobiological mechanisms. The current study recruited healthy young adults to investigate the effects of a single bout of moderate-to-vigorous intensity aerobic exercise on subsequent performance and pupillary responses during an inhibitory control task. Results showed that an acute bout of exercise was related to shorter reaction times and increased tonic pupil dilation during an inhibitory control task. Although pupillary responses did not mediate the acute exercise effect on inhibitory control, higher cardiorespiratory fitness was associated with greater phasic pupil dilation following exercise relative to seated rest. The current study supported the plausibility of the pupillary response as a marker of LC-NE system activation that is sensitive to acute exercise. Whether pupillary responses could account for transient benefits of acute exercise on brain and cognition remains unclear.

Little is known about quality of life (QOL) at the time of multiple sclerosis (MS) or clinically isolated syndrome (CIS) diagnosis and how it evolves in the critical adjustment period immediately following a new diagnosis. To (1) describe QOL trajectory in the first year post-MS/CIS diagnosis and (2) examine associations of demographic and biopsychosocial factors with QOL at baseline and as it evolves over the first year post-MS/CIS diagnosis. Participants were N = 250 individuals newly diagnosed with MS or CIS. Participants completed self-report assessments of QOL, demographics, and biopsychosocial factors at 1, 2, 3, 6, 9, and 12 months post-diagnosis using validated measures. At 1-month post-diagnosis, QOL M = 75.2/100 with subsequent assessments revealing consistent ratings on average. Modelling revealed a small number of variables that were predictive of QOL at baseline and/or change in QOL over time. QOL in the first year post-MS/CIS diagnosis was, on average, high and stable. A subset of modifiable factors across the biopsychosocial spectrum was associated with baseline level of QOL and change in QOL over time. The stability in QOL suggests that patients can be assessed early after diagnosis for key variables that are predictive of both current and future QOL.

Barium defecography can assess structural and functional abnormalities in patients with chronic constipation.The purpose of this study was to determine the prevalence of individual and overlapping defecographic findings in this setting.This was a cross-sectional study.The study was conducted at a university hospital tertiary GI physiology department.Consecutive examinations of 827 consecutive patients presenting over a 30-month period with well-defined symptom severity (≥12 points on the Cleveland Clinic Constipation score) were included. Systematic evaluation of images with results stratified by sex is described.Six individual functional or anatomic (intussusception, rectocele, enterocele, megarectum, excessive dynamic perineal descent) defecographic observations were defined a priori, thus permitting 26 possible combinations of findings (ie, 63 abnormal types + 1 normal).Patients with constipation (mean symptom score = 19) were predominantly female (88%), with median age of 49 years (range, 17-98 y) . All 6 individual radiologic findings were identified with a total of 43 combinations found in the cohort; the 14 most prevalent of these accounted for85% of patients. Only 136 patients (16.4%) had a normal defecography (34.3% males vs 13.9% females; p0.0001). Overall, 612 patients (74.0%) had structural (n = 508 (61.4%)) or functional (n=104 (12.6%)) abnormalities in isolation, with 79 (9.6%) others exhibiting combinations of both. Functional abnormalities in isolation were more common in males compared with females (22.5% vs11.2%; p = 0.025) as opposed to structural abnormalities (57.8% vs 85.7%; p0.0001). Expulsion time was longer in females compared with males (110 s (60-120 s) vs 90 s (60-120 s); p = 0.049).The study was limited by its lack of multiorgan opacification.These results provide a contemporary atlas of defecographic findings in constipation. Several individual structural and functional features have been systematically classified, with overlap greater than previously acknowledged and profound differences among sexes that carry implications for tailoring management. See Video Abstract at http://links.lww.com/DCR/B552.ANTECEDENTES:La defecografía con bario puede evaluar anomalías estructurales y funcionales en pacientes con estreñimiento crónico.OBJETIVO:Determinar la prevalencia de hallazgos defecográficos individuales y superpuestos en este entorno.DISEÑO:Transversal.ENTORNO CLINICO:Hospital Universitario de tercer nivel, departamento de fisiología gastrointestinal.PACIENTES:Exploraciones consecutivas de 827 pacientes consecutivos que se presentaron durante un período de 30 meses con una gravedad de los síntomas bien definida (≥12 puntos en la escala de estreñimiento de la Cleveland Clinic): evaluación sistemática de imágenes con resultados estratificados por sexo.PRINCIPALES MEDIDAS DE VALORACION:Se definieron a priori seis observaciones defecográficas individuales, funcionales o anatómicas (intususcepción, rectocele, enterocele, megarecto, descenso perineal dinámico excesivo), lo que permitió 26 combinaciones posibles de hallazgos (es decir, 63 tipos anormales + 1 normal).RESULTADOS:Los pacientes con estreñimiento (puntuación media de síntomas, 19) eran predominantemente mujeres (88%) con una edad mediana de 49 (17-98) años. Se identificaron 6 hallazgos radiológicos individuales con un total de 43 combinaciones encontradas en la cohorte; los 14 más predominantes de éstos representaron85% de los pacientes.Solo 136 (16,4%) pacientes tuvieron una defecografía normal (34,3% hombres vs. 13,9% mujeres; P0,0001). En general, 612 (74,0%) pacientes tenían anomalías estructurales (n = 508 [61,4%]) o funcionales (n = 104 [12,6%]) de forma aislada, y otros 79 (9,6%) presentaban combinaciones de ambas. Las anomalías funcionales aisladas fueron más comunes en los hombres en comparación con las mujeres (22,5% vs. 11,2%, P = 0,025) en comparación con las anomalías estructurales (57,8 vs. 85,7%, P0,0001). El tiempo de expulsión fue mayor en las mujeres en comparación con los hombres (110 [60-120] vs. 90 [60-120] segundos; P = 0,049).LIMITACIONES:Falta de opacificación multiorgánica.CONCLUSIONES:Estos resultados proporcionan un atlas contemporáneo de hallazgos defecográficos en estreñimiento. Varias características individuales, estructurales y funcionales; se han clasificado sistemáticamente, con una superposición mayor que la reconocida anteriormente y con grandes diferencias entre los sexos que tienen implicaciones para adaptar su tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B552.

Background: Braak and others have proposed that Lewy-type α-synucleinopathy in Parkinson’s disease (PD) may arise from an exogenous pathogen that passes across the gastric mucosa and then is retrogradely transported up the vagus nerve to the medulla. Objective: We tested this hypothesis by immunohistochemically staining, with a method specific for p-serine 129 α-synuclein (pSyn), stomach and vagus nerve tissue from an autopsy series of 111 normal elderly subjects, 33 with incidental Lewy body disease (ILBD) and 53 with PD. Methods: Vagus nerve samples were taken adjacent to the carotid artery in the neck. Stomach samples were taken from the gastric body, midway along the greater curvature. Formalin-fixed paraffin-embedded sections were immunohistochemically stained for pSyn, shown to be highly specific and sensitive for α-synuclein pathology. Results: Median disease duration for the PD group was 13 years. In the vagus nerve none of the 111 normal subjects had pSyn in the vagus, while 12/26 ILBD (46%) and 32/36 PD (89%) subjects were pSyn-positive. In the stomach none of the 102 normal subjects had pSyn while 5/30 (17%) ILBD and 42/52 (81%) of PD subjects were pSyn-positive. Conclusion: As there was no pSyn in the vagus nerve or stomach of subjects without brain pSyn, these results support initiation of pSyn in the brain. The presence of pSyn in the vagus nerve and stomach of a subset of ILBD cases indicates that synucleinopathy within the peripheral nervous system may occur, within a subset of individuals, at preclinical stages of Lewy body disease.

Deficits in upper and lower urinary tract function, which include detrusor overactivity, urinary incontinence, detrusor-sphincter dyssynergia, and polyuria, are among the leading issues that arise after spinal cord injury (SCI) affecting quality of life. Given that overproduction of urine (polyuria) has been shown to be associated with an imbalance in key regulators of body fluid homeostasis, the current study examined the timing of changes in levels of various relevant hormones, peptides, receptors, and channels post-contusion injury in adult male Wistar rats. The results show significant up- or downregulation at various time points, beginning at 7 days post-injury, in levels of urinary atrial natriuretic peptide, serum arginine vasopressin (AVP), kidney natriuretic peptide receptor-A, kidney vasopressin-2 receptor, kidney aquaporin-2 channels, and kidney epithelial sodium channels (β- and γ-, but not α-, subunits). The number of AVP-labeled neurons in the hypothalamus (supraoptic and -chiasmatic, but not paraventricular, nuclei) was also significantly altered at one or more time points. These data show significant fluctuations in key biomarkers involved in body fluid homeostasis during the post-SCI secondary injury phase, suggesting that therapeutic interventions (e.g., desmopressin, a synthetic analogue of AVP) should be considered early post-SCI.

BACKGROUND: The following case report describes the first known case of McLeod Syndrome in a commercial airline pilot. The case describes a 56-yr-old experienced pilot who showed a slow and subtle decline in cognitive function and muscle control in the cockpit. On further examination, the pilots erratic behavior and movement along with lab abnormalities pointed toward McLeod Syndrome. CASE REPORT: The pilot was recommended for evaluation by his fellow crewmembers due to his fidgetiness, clumsiness, and lack of focus during critical portions of flight. The pilot reported having a long-standing history of elevated CK levels. Further lab investigations revealed acanthocytes on blood smear while neurological evaluation detected chorea. The combination of clinical and laboratory features along with genetic test results were all consistent with McLeod Syndrome. DISCUSSION: The case highlights how subtle behavioral and motor coordination changes can be a warning sign for an underlying progressive neurological disorder that requires further workup and referral. Haas C, Levin D, Milone M, Vardiman-Ditmanson J, Mathers C. McLeod syndrome in a commercial airline pilot. Aerosp Med Hum Perform. 2021; 92(9):734737.

BACKGROUND CONTEXT Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN A Modified Delphi process was used. METHODS The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 – 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website ( https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria) .

Following the discovery of heart regeneration in zebrafish, several more species within the Cyprinidae family have been found to have the same capability, suggesting heart regeneration may be conserved within this family. Although gonad regeneration has been observed in grass carp (Ctenopharyngodon idella), one of the largest cyprinid fish, the species’ response to cardiac injury has not been characterized. Surprisingly, we found cardiomyocytes do not repopulate the injured region following cryoinjury to the ventricle, instead exhibiting unresolved fibrosis and decreased cardiac function that persists for the 8-week duration of this study. Compared to other cyprinid fish studied, infiltration of macrophages is delayed and muted in this model. Additionally, fibroblasts are depleted following injury, a phenomenon not previously described in any cardiac model. This study shows that heart regeneration is not conserved among the Cyprinidae family and suggests the important role of non-fibroblasts in chronic fibrosis. Further study of these phenomenon may reveal the underlying differences between regeneration versus unresolved fibrosis in heart disease.Summary statementGrass carp, a member of the Cyprinidae family that includes regenerative zebrafish, do not regenerate functional cardiac tissue after cryoinjury. Instead, healing progresses through collagen deposition and scar formation.

Background Patients desire face-lifting procedures primarily to appear younger, more refreshed, and attractive. Because there are few objective studies assessing the success of face-lift surgery, the authors used artificial intelligence, in the form of convolutional neural network algorithms alongside FACE-Q patient-reported outcomes, to evaluate perceived age reduction and patient satisfaction following face-lift surgery. Methods Standardized preoperative and postoperative (1 year) images of 50 consecutive patients who underwent face-lift procedures (platysmaplasty, superficial musculoaponeurotic system-ectomy, cheek minimal access cranial suspension malar lift, or fat grafting) were used by four neural networks (trained to identify age based on facial features) to estimate age reduction after surgery. In addition, FACE-Q surveys were used to measure patient-reported facial aesthetic outcome. Patient satisfaction was compared to age reduction. Results The neural network preoperative age accuracy score demonstrated that all four neural networks were accurate in identifying ages (mean score, 100.8). Patient self-appraisal age reduction reported a greater age reduction than neural network age reduction after a face lift (-6.7 years versus -4.3 years). FACE-Q scores demonstrated a high level of patient satisfaction for facial appearance (75.1 ± 8.1), quality of life (82.4 ± 8.3), and satisfaction with outcome (79.0 ± 6.3). Finally, there was a positive correlation between neural network age reduction and patient satisfaction. Conclusion Artificial intelligence algorithms can reliably estimate the reduction in apparent age after face-lift surgery; this estimated age reduction correlates with patient satisfaction. Clinical question/level of evidence Diagnostic, IV.

An increasing number of studies has focused on the after-effects of acute aerobic exercise on executive function. To date, empirical evidence lacks consensus regarding whether acute aerobic exercise has beneficial effects on executive function. To identify possible sources of this discrepancy, the present study focused on executive function demands and pre-test cognitive performance, and performed the first meta-analysis of individual participant data (IPD meta-analysis) in this area of research. Results indicated that the beneficial after-effects of acute aerobic exercise on cognitive performance were greater in participants with lower cognitive performance at pre-test. Acute aerobic exercise offered general benefits to cognitive performance irrespective of executive function demands, when pre-test cognitive performance was appropriately controlled. Thus, the present IPD meta-analysis suggests that pre-test cognitive performance is one possible source of the conflicting findings in acute exercise studies. Future research is encouraged to consider pre-test cognitive performance to avoid underestimating the beneficial after-effects of acute exercise.

Describe driving patterns following moderate-to-severe traumatic brain injury (TBI). Participants: Adults (N = 438) with TBI that required inpatient acute rehabilitation who had resumed driving.Cross-sectional, observational design.Eight TBI Model System sites.A driving survey was completed at phone follow-up.Most respondents reported driving daily, although 41% reported driving less than before their injury. Driving patterns were primarily associated with employment, family income, sex, residence, and time since injury, but not injury severity. Confidence in driving was high for most participants and was associated with a perception that the TBI had not diminished driving ability. Lower confidence and perceived loss of ability were associated with altered driving patterns.Most people with moderate-to-severe TBI resume driving but perhaps not at pre-injury or normal levels compared to healthy drivers. Some driving situations are restricted. The relationship between low confidence/perceived loss of ability and driving patterns/restrictions suggests people with TBI are exhibiting some degree of caution consistent with those perceptions. Careful assessment of driving skills and monitoring during early stages of RTD is warranted, particularly for younger, male, and/or single drivers who express higher levels of confidence.

Concussion imaging research has primarily focused on neuronal disruption with lesser emphasis directed toward vascular dysfunction. However, blood flow metrics may be more sensitive than measures of neuronal integrity. Vascular dysfunction can be assessed by measuring cerebrovascular reactivity (CVR)-the change in cerebral blood flow per unit change in vasodilatory stimulus. CVR metrics, including speed and magnitude of flow responses to a standardized well-controlled vasoactive stimulus, are potentially useful for assessing individual subjects following concussion given that blood flow dysregulation is known to occur with traumatic brain injury. We assessed changes in CVR metrics to a standardized vasodilatory stimulus during the acute phase of concussion. Using a case control design, 20 concussed participants and 20 healthy controls (HCs) underwent CVR assessment measuring blood oxygen-level dependent (BOLD) magnetic resonance imaging using precise changes in end-tidal partial pressure of CO2 (PETCO2). Metrics were calculated for the whole brain, gray matter (GM), and white matter (WM) using sex-stratification. A leave-one-out receiver operating characteristic (ROC) analysis classified concussed from HCs based on CVR metrics. CVR magnitude was greater and speed of response faster in concussed participants relative to HCs, with WM showing higher classification accuracy compared with GM. ROC analysis for WM-CVR metrics revealed an area under the curve of 0.94 in males and 0.90 in females for speed and magnitude of response respectively. These greater than normal responses to a vasodilatory stimulus warrant further investigation to compare the predictive ability of CVR metrics against structural injury metrics for diagnosis and prognosis in acute concussion.

Background Hyposmia is characteristic of idiopathic Parkinson's disease (PD) and dementia with Lewy bodies (DLBs), whereas progressive supranuclear palsy (PSP) typically has normal sense of smell. However, there is a lack of pathologically confirmed data. Objective The objective is to study hyposmia in pathologically confirmed PSP patients and compare to PD patients and nondegenerative controls. Methods We studied autopsied subjects in the Arizona Study of Aging and Neurodegenerative Disorders who had antemortem olfactory testing and a neuropathological diagnosis of either PD, PSP, or control. Results This study included 281 cases. Those with neuropathologically confirmed PSP (N = 24) and controls (N = 174) had significantly better sense of smell than those with PD (N = 76). Although most PSP patients had normal olfaction, there were some with hyposmia, resulting in an overall reduced sense of smell in PSP compared to controls. The sensitivity of having PSP pathologically in those presenting with parkinsonism and normosmia was 93.4% with a specificity of 64.7%. Cases with both PSP and PD pathologically had reduced sense of smell similar to PD alone (N = 7). Hyposmic PSP patients had significantly higher Lewy body burden not meeting criteria for additional PD/DLB diagnosis. Conclusions Pathologically confirmed PD had reduced olfaction compared with PSP or controls. In the setting of parkinsonism in this sample, the presence of normosmia had high sensitivity for PSP. Hyposmia in PSP suggests the presence of additional Lewy body pathology. © 2021 International Parkinson and Movement Disorder Society.

Background Stereotactic radiosurgery (SRS) is used to manage intracranial metastases in a significant fraction of patients. Local progression after SRS can often only be detected with increased volume of enhancement on serial MRI scans which may lag true progression by weeks or months. Methods Patients with intracranial metastases (N = 11) were scanned using hyperpolarized $$^{13}$$ 13 C MRI prior to treatment with stereotactic radiosurgery (SRS). The status of each lesion was then recorded at six months post-treatment follow-up (or at the time of death). Results The positive predictive value of $$^{13}$$ 13 C-lactate signal, measured pre-treatment, for prediction of progression of intracranial metastases at six months post-treatment with SRS was 0.8 $$p < 0.05$$ p < 0.05 , and the AUC from an ROC analysis was 0.77 $$p < 0.05$$ p < 0.05 . The distribution of $$^{13}$$ 13 C-lactate z-scores was different for intracranial metastases from different primary cancer types (F = 2.46, $$p = 0.1$$ p = 0.1 ). Conclusions Hyperpolarized $$^{13}$$ 13 C imaging has potential as a method for improving outcomes for patients with intracranial metastases, by identifying patients at high risk of treatment failure with SRS and considering other therapeutic options such as surgery.

Background Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI. Objective To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions. Methods A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted. Results Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033). Conclusion RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.

Myotonic dystrophy type 2 (DM2) is an autosomal dominant disorder due to a (CCTG)n repeat expansion in intron 1 of the CNBP gene. In this article, we report the clinicopathologic findings in 50 patients seen at a single site over a 27 year period. DM2 was the fifth most common type of muscular dystrophy seen at our center with a 5-fold lower frequency as compared to DM1. Age of symptom onset ranged from 15 to 72 years, and the mean duration between symptom onset and diagnosis was 7.4 years. Weakness referable to the proximal lower extremities was the presenting symptom in 62% of patients. The degree of generalized weakness varied from severe in 30% to no weakness in 20% of patients. Clinical myotonia was noted in 18% and myotonic discharges on electromyography in 97% of patients. Pain symptoms were uncommon in our cohort. A significant correlation was noted between limb weakness and degree of muscle pathologic changes. There was no correlation between CCTG repeat size and other clinicopathologic findings. Six patients (12%) had cardiac abnormalities including one who developed progressive nonischemic dilated cardiomyopathy ultimately leading to cardiac transplantation. In 21 patients followed for 2 or more years, we noted a mean rate of decline in total Medical Research Council score of about 1% per year.

OBJECTIVE: Early psychosocial deprivation increases the risk of later cognitive and psychiatric problems, but not all deprived children show these difficulties. Here, we examine the extent to which psychosocial deprivation increases the risk of later cognitive and psychiatric difficulties and the downstream consequences of this for risk-taking behavior in adolescence. METHOD: Children abandoned to institutions early in life were randomly assigned to care-as-usual or a foster care intervention during infancy. A separate group of never-institutionalized children was recruited as a comparison sample. The current follow-up study included 165 children (51% female), 113 with a history of institutionalization and 52 with no such history. At age 12, caregivers reported on children’s psychiatric difficulties, and their IQ was assessed by standardized testing. At 16 years, risk-taking behavior was assessed from youth self-reports. RESULTS: Latent profile analysis revealed three subgroups of children with varying levels of cognitive and psychiatric difficulties: Low-Morbidity (n = 104, 62.7%), Medium-Morbidity (n = 46, 27.9%), and High-Morbidity (n = 15, 9.4%). Nearly half of the institutionalized children belonged to the High- or Medium-Morbidity subgroups; and institutionally-reared children were significantly more likely to belong to one of these profiles than never-institutionalized children. Compared to the Low-Morbidity subgroup, membership in the Medium-Morbidity profile was associated with higher levels of risk-taking behavior at age 16 years. CONCLUSIONS: Children who experience psychosocial deprivation are considerably more likely to present with elevated cognitive and psychiatric difficulties in early adolescence and, for some children, this elevation is linked to heightened risk-taking behavior in adolescence.

Persisting concussion symptoms (PCS) can last for months, years, or indefinitely and affect a considerable number of concussion patients. The objectives of this study were to evaluate the prevalence of clinical symptoms of anxiety and depression and the relationship between PCS and quality of life in patients examined at the Canadian Concussion Centre. The Depression and Anxiety Stress Scale-42 (DASS-42) and the World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF) were sent to 526 adult patients diagnosed with PCS. Median with interquartile range follow-up time was 5 (4-7) years. Of the 105 respondents, 35.2% displayed mild or greater symptoms of anxiety, depression, or both. Importantly, the number of previous concussions was correlated with elevations on the DASS-42 Anxiety (

This study investigated the effects of high-intensity interval training (HIIT) and moderate-intensity continuous exercise (MICE) on behavioral performance and neural correlates of working memory. Thirty-six 18–30 years adults were recruited to perform a 20-min bout of HIIT, MICE, and rest on separate days in counterbalanced order. Following interventions, frontal alpha event-related desynchronization (ERD) was measured during a modified Sternberg task requiring varying amounts of working memory (3-, 5-, 7-letter tasks). Behavioral analyses showed a condition effect, indicating shorter response times following HIIT compared to rest. Analysis of frontal alpha ERD showed an interaction of condition and task, indicating no differences across tasks following rest but a task effect following HIIT and MICE, with frontal alpha ERD increasing in the 7-letter task compared with the 3-letter task. Following HIIT, this task-related contrast of frontal alpha ERD extended to the time period when memory retrieval occurred. Although both HIIT and MICE resulted in alterations in neuroelectric underpinnings of memory encoding and retention in response to increased memory load, only HIIT enhanced the processing speed and brain activation during memory retrieval. These findings provide evidence for potential applications of exercise to enhance working memory and the role of exercise type to such effect.

Background Though many trauma patients are on anticoagulation or antiplatelet therapy (AAT), there are few generalizable data on the risks for these patients. The purpose of this study was to analyze the impact of anticoagulation (AC) and antiplatelet (AP) therapy on mortality and length of stay (LOS) in general trauma patients. Methods A retrospective review was performed of patients in the institutional trauma registry during 2019 to determine AAT use on admission and discharge. Outcomes were compared using standard statistics. Results Of 2261 patients who met the inclusion criteria, 2 were excluded due to an incomplete medication reconciliation, resulting in 2259 patients. Patients on AAT had a higher mortality (4.5% vs 2.1%). On multivariable analysis, preadmission AC (odds ratio OR, 3.325, P = .001), age (OR 1.040, P < .001), and injury severity score ((ISS) 1.094, P < .001) were associated with mortality. Anticoagulation use was also associated with longer LOS on multivariable analysis (OR: 1.626, P = .005). Antiplatelet use was not associated with higher mortality or longer LOS. More patients on AAT were unable to be discharged home. However, patients on AAT did not have a greater blood transfusion requirement or need more hemorrhage control procedures. Lastly, 23.7% of patients on preadmission AAT were not discharged on any AAT. Discussion These data demonstrate that patients on AC, but not AP, have greater mortality and longer hospital LOS. This may provide guidance for those being newly started on AAT. Further work to determine which patients benefit most from restarting AAT would lead to improvement in the care of trauma patients.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with poor prognosis, particularly for patients with metastatic disease. Treatment for oligometastatic presentation has been reported in recent literature, but the role of intraperitoneal chemotherapy for patients with peritoneal metastases (PM) remains unclear. We performed a systematic literature search of the PubMed, Cochrane and Embase databases in order to identify clinical trials and case-series reporting on the safety and efficacy of intraperitoneal chemotherapy in patients with PDAC-derived PM. Eight publications reporting on 85 patients were identified, using three different therapeutic strategies. First, 37 patients received cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for PDAC with PM. Grade 3 and 4 complications occurred in 37.8% of patients, without perioperative mortality. Median disease-free survival and overall survival (OS) rates varied from 4 to 36 months and 4 to 62 months, respectively. Secondly, 40 patients with resectable PDAC without PM received prophylactic HIPEC following pancreatic resection, with postoperative morbidity and mortality rates of 30% and 5%, and 5-year OS rates of 23-24%. Finally, eight patients with PDAC-derived peritoneal disease were converted to resectable disease after receiving neoadjuvant intraperitoneal chemotherapy and operated on with curative intent, achieving a median OS of 27.8 months. In conclusion, CRS with HIPEC for PDAC-derived PM appears to be safe, conferring the same postoperative morbidity and mortality as reported on non-pancreatic malignancies. In highly selected patients, it could be considered for short-term disease control. However, long-term survival remains poor. The addition of prophylactic HIPEC for resectable PDAC cannot be recommended.

CONTEXT: This scoping review examines the current research on the effect of cannabis upon pain intensity in spinal cord injury (SCI) pain. Chronic pain is a significant secondary condition following SCI, and traditional treatments (e.g. opioids, NSAIDs) are often criticized for providing inadequate relief. As a result, there is increasing interest in and use of cannabis and cannabinoid-based medications as an alternative means of pain control. OBJECTIVE: The purpose of this review was to examine the scientific evidence on the effect of cannabis/cannabinoids upon pain intensity in SCI by mapping the current literature. METHODS: Two hundred and fifty-two studies were identified by searching electronic databases for articles published through February 2020. In addition, reviewers scanned the reference lists of identified articles and examined clinicaltrials.gov for unpublished data in this area. Title, abstract, and full-text reviews were completed by two independent reviewers. Data extraction was performed by a single reviewer and verified by a second reviewer. RESULTS: Six articles covering five treatment studies were included. Studies yielded mixed findings likely due to large variability in methodology, including lack of standardized dosing paradigms, modes of use, and duration of trial. CONCLUSIONS: The current quality and level of evidence is insufficient to draw reliable conclusions of the efficacy of cannabis upon SCI-related pain itensity. We identify specific limitations of past studies and present guidelines for future research. Trial registration: ClinicalTrials.gov identifier: Nct01606202..

OBJECTIVELumbar fusion can lead to significant improvements in patient-reported outcomes (PROs) in patients with degenerative conditions. It is unknown whether the presence of hip or knee arthritis confounds the responses of patients to low-back–specific PROs. This study examined PROs with lumbar fusion in patients with concomitant lower-extremity arthritis. The purpose of the current study was to examine whether patients with significant lower-extremity arthritis who undergo lumbar fusion achieve similar improvements in low-back–specific PROs compared to patients without lower-extremity arthritis.METHODSPatients were identified from a prospectively enrolled multicenter registry of patients undergoing lumbar fusion surgery for degenerative conditions. Two hundred thirty patients identified with lumbar fusion and who also had concomitant lower-extremity arthritis were propensity matched to 233 patients who did not have lower-extremity arthritis based on age, BMI, sex, smoking status, American Society of Anesthesiologists grade, number of levels fused, and surgical approach. One-year improvement in PROs, numeric rating scales (0–10) for back and leg pain, and the Oswestry Disability Index and EuroQol-5D scores were compared for patients with and without lower-extremity arthritis.RESULTSBaseline demographics and preoperative outcome measures did not differ between the two propensity-matched groups with 110 cases each. Patients with concomitant lower-extremity arthritis achieved similar improvement in health-related quality-of-life measures to patients without lower-extremity arthritis, with no significant differences between the groups (p > 0.10).CONCLUSIONSThe presence of lower-extremity arthritis does not adversely affect the results of lumbar fusion in properly selected patients. Patients with lower-extremity arthritis who undergo lumbar fusion can achieve meaningful improvement in PROs similar to patients without arthritis.

Professor Sir Richard Doll, in collaboration with Professor Sir Austin Bradford Hill, were the first to quantitate the relationship of cigarette smoking with lung cancer.1 Later, Doll aptly stated, “Death in old age is inevitable, but death before old age is not.”1 The Richard Doll Building at the University of Oxford in Oxford, England, is inscribed with one of Doll's many impactful statements about cigarette smoking: In previous centuries, 70 years used to be regarded as humanity's allotted span of life, and only about one in five lived to such an age. Nowadays, however, for non-smokers in Western countries, the situation is reversed: only about one in five will die before 70, and the non-smoker death rates are still decreasing, offering the promise, at least in developed countries, of a world where death before 70 is uncommon.1 Despite this evidence-based optimism, cigarette smoking and the emerging clinical and public health challenges of overweight and obesity and physical inactivity are the leading avoidable causes of premature death in most industrialized nations. These risk factors are also emerging in the rest of the world, so that smoking, overweight and obesity, and physical inactivity are the major contributors to the reason that cardiovascular disease (CVD) has increased from number 5 to number 1 as the cause of mortality worldwide.2 In the United States during the past several decades (since 1965), the prevalence of cigarette smoking has decreased markedly.3 Nonetheless, in 2018, approximately 34.2 million Americans aged 18 years and older, or 13.7% of the population, were current cigarette smokers.3 Thus, the impact of cigarette smoking on avoidable and premature mortality remains alarmingly high. In the United States alone, smoking causes more than 480,000 deaths each year.3 These sobering statistics reflect, in major ways, the approximate 2-fold increased risk of CVD among current smokers and the approximate 20-fold increased risk of lung cancer among long-term smokers. Specifically, these relative increases translate to absolute increases of more than 150,000 deaths per year from CVD and 130,000 deaths per year from lung cancer among persons ≥35 years of age.4 Quitting smoking before age 40 years reduces the risk of dying from cigarette-related disease by approximately 90%.5 Specifically, smoking cessation significantly reduces the risks of CVD—beginning within a matter of months—and the risk of CVD among those who quit smoking equals that of lifelong nonsmokers within a few years, even among older adults.6 In contrast, reductions in mortality risk from lung cancer only begin to appear several years after quitting, and even by 10 years, the risk has been reduced to only approximately midway between continuing smokers and lifelong nonsmokers.7 In the United States in 2016, approximately 30 million hospital admissions occurred among persons 18+ years of age, with an average length of stay of 4.6 days.8 A 2009 study in San Francisco reported the prevalence of cigarette smoking among hospitalized patients to be 40%9 in contrast to the prevalence in the general population of 13.7%.3,10 This prevalence implies that up to 12 million inpatients in US hospitals are smokers. In this paper, we discuss effective and safe counseling and drug therapies that have the potential to prevent numerous premature deaths in the United States caused by cigarettes in hospitalized smokers.

The purpose of this study was to determine if setting mean arterial pressure (MAP) targets during cardiopulmonary bypass (CPB) based on individualized cerebral autoregulation data reduces the frequency of neurological complications compared with usual care. Patients (n = 460) ≥ 55 years old at risk for neurological complications were randomized to have MAP targets during CPB to be above the lower limit of transcranial Doppler determined cerebral autoregulation versus usual institutional practices. The primary outcome was the frequency of the composite endpoint of clinical stroke, or new brain magnetic resonance imaging-detected ischemic injury, or cognitive decline 4-6 weeks after surgery from baseline. Secondary outcomes were components of the primary composite outcome and clinically detected delirium. Complete outcome data were available from 194 patients (stroke assessments, n = 460; magnetic resonance imaging data, n = 164; cognitive data n = 336). There was no difference between groups in the frequency of the composite neurological end-point or its components (P = 0.752). Compared with the usual care there was a 45% reduction in the frequency of clinically detected delirium in the autoregulation group (8.2% vs 14.9%, risk ratio = 0.55, 95% confidence interval = 0.32, 0.93, P = 0.035) and improved performance on test of memory 4-6 weeks after surgery from baseline (P = 0.019). Basing MAP during CPB on cerebral autoregulation monitoring did not reduce the frequency of the primary neurological outcome in high-risk patients compared with usual care but it was associated with a reduction in the frequency of delirium and better performance on tests of memory 4-6 weeks after surgery.

Highlights • Cardiorespiratory fitness was associated with older adolescents’ cognitive control. • Muscular fitness was not associated with older adolescents’ cognitive control. • Cardiorespiratory fitness selectively influences cognition in late adolescence., Background Participation in physical activity supports greater cardiorespiratory fitness (CRF), a correlate of cognitive control. However, the relationship between muscular fitness (MF) and cognitive control is less clear. The present study investigated the differential relationship of CRF and MF with cognitive control in older adolescents. Methods This cross-sectional study involved students (15–17 years old, n = 541, 43% female) from 20 secondary schools who completed tests of inhibition (modified flanker task), working memory (n-back task), CRF (Progressive Aerobic Cardiovascular Endurance Run), and MF (standing long jump and push-up test). Multilevel analyses tested the association between CRF or MF and cognitive outcomes while accounting for the influence of the other fitness variable and relevant demographic factors. Results CRF predicted response accuracy during incongruent flanker trials, the condition requiring greater inhibition. For the working memory task, CRF predicted greater target accuracy and greater d' scores on the 1-back task, requiring lesser amounts of working memory. In the 2-back task, which requires greater amounts of working memory, CRF also predicted greater target and non-target accuracy and d' scores. Comparatively, MF did not predict any cognitive outcomes after adjustment for CRF. Conclusion CRF was selectively related to better performance during task conditions that require greater amounts of inhibition and working memory. This finding suggests that CRF, but not MF, may benefit cognitive control in older adolescents. This selective influence of CRF on older adolescents’ cognition highlights the value of aerobic physical activity., Graphical Abstract Image, graphical abstract

(Van Wijk CH, Martin JH, Firfirey N. Common mental health conditions among navy divers: A brief report. Diving and Hyperbaric Medicine. 2020 December 20;50(4):417–420. doi: 10.28920/dhm50.4.417-420. PMID: 33325025.) Introduction: A recent article reported on common mental health conditions among recreational scuba divers, and observed that the prevalence mirrored national population figures. This raised the question of the extent to which this might also be the case among professional divers. No data on commercial divers could be located; this paper presents the situation among navy divers. Methods: Mental health survey data from 132 South African Navy divers were reviewed to describe the 12-month prevalence of common mood, anxiety, and alcohol misuse disorders. Results: Prevalence of common mood and anxiety conditions appeared to reflect local general population estimates, and the occurrence of alcohol misuse was higher than local population figures, although the usefulness of the population data could be challenged. Conclusions: It appeared that common mental health conditions in both sport and navy divers may generally conform to their respective local general population estimates. If this were to be the case in the broader professional diving environment as well, the inclusion of some form of formal mental health screening during commercial diving medical examinations may be beneficial.

INTRODUCTION Normal bowel function requires intact sensory pathways. Diminished rectal sensation (rectal hyposensitivity [RH]) is associated with constipation, although its clinical importance remains unclear. METHODS Consecutive patients (aged 18-80) attending a tertiary center (2004-2016) for investigation of refractory functional constipation (Rome IV core criteria defined, applied post hoc) were included. Patients completed a clinical symptom questionnaire and underwent anorectal physiologic investigations, including rectal sensory testing (balloon distension) to determine 3 well-established sensory thresholds. Multivariate regression analyses were performed to evaluate associations between RH, symptomology, and allied physiologic investigations. RESULTS Of 2,876 patients meeting inclusion criteria, 722 (25%) had RH based on ≥1 elevated sensory thresholds (0: n = 2,154 [74.9%]; 1: n = 327 [11.4%]; 2: n = 209 [7.3%]; and 3: n = 186 [6.5%]). A linear relationship existed between increasing number of elevated sensory thresholds and constipation severity (Cleveland Clinic constipation score: mean difference per threshold [95% confidence interval] 0.69 [0.48-0.90]; P < 0.001). Several symptoms were significantly (P < 0.05) associated with RH including: infrequent defecation (odds ratio 1.29 [1.17-1.42]), painful evacuation (1.15 [1.05-1.27]), prolonged toileting (1.14 [1.05-1.24]), and digitation or enema use (1.18 [1.08-1.30]). On defecography, a "functional" evacuation disorder was also associated with RH (1.37 [1.25-1.50], P < 0.001), as was megarectum (2.52 [2.08-3.05], P < 0.001). DISCUSSION RH occurs in 25% of patients with refractory functional constipation. Increased number of elevated sensory thresholds is associated with more severe constipation phenotype. These data, in the largest study to date, provide for the first time evidence to show that RH is a major pathophysiologic mechanism in constipation, with recognized clinical impact (http://links.lww.com/AJG/B765).(Equation is included in full-text article.).

We examined the hypothesis that exaggerating unloading-induced bone loss using a combination of hindlimb suspension (HLS) and exogenous injections of receptor activator of nuclear factor kappa-B ligand (RANKL) also exaggeratesgastrocnemius and quadriceps muscle loss. Forty, male C57Bl/6J mice (16 weeks) were subjected to HLS or normal ambulation (ground control, GC) for 14 days. Mice received 3 intraperitoneal injections of either human recombinant soluble RANKL or PBS as control (n=10/group) at 24 hour intervals starting on Day 1 of HLS. GC + RANKL and HLS mice exhibited similar decreases in trabecular bone volume and density in both proximal tibias and distal femurs. However, RANKL affected trabecular number, separation, and connectivity density, while HLS decreased trabecular thickness. The combination of RANKL and HLS exacerbated these changes. Similarly,GC + RANKL and HLS mice saw comparable decreases in cortical bone volume, thickness, and strength in femur midshafts, and combination treatment exacerbated these changes. Plasma concentrations of P1NP were increased in both groups receiving RANKL, while CTX concentrations were unchanged.HLS decreased gastrocnemius weight and was associated with a reduction in global protein synthesis, and no change in proteasome activity. This change was correlated with a decrease in S6K1 and S6 phosphorylation, but no change in 4E-BP1 phosphorylation. Injection of RANKL did not alter gastrocnemius or quadriceps muscle protein metabolism in GC or HLS mice.Our results suggest that injection of soluble RANKL exacerbates unloading-induced bone loss, but not unloading-induced gastrocnemius or quadriceps muscle loss. This article is protected by copyright. All rights reserved.

OBJECTIVE Early psychosocial deprivation is associated with increased risk for psychopathology, yet few studies have examined outcomes in adolescents. METHOD At baseline (M age 22 months), 136 children from Bucharest, Romania, living in large institutions, were randomized into foster care (FCG) or to care as usual (CAUG). Caregivers completed psychiatric interviews regarding their children (52 FCG; 51 CAUG) at age 16 years (M = 16.67 years; SD = 0.78) to assess past year diagnoses and symptom counts. In addition, never-institutionalized community comparison children (n = 47) were included. RESULTS Ever-institutionalized children had higher rates of meeting criteria for any psychiatric disorder and higher symptom counts of internalizing, externalizing, attention-deficit/hyperactivity, and substance use disorders compared to never-institutionalized children (ps < .05). Using intent-to-treat analyses, we found that children in the CAUG had more than twice the rate of psychiatric disorders than children in the FCG (OR = 2.48, 95% CI [1.12, 5.48]). Furthermore, children in foster care who remained in their original placement did not significantly differ in their rates of psychiatric disorders compared to never-institutionalized children. CONCLUSIONS There are many ways children can be separated from parents, including placement into institutional care. The current findings indicate that such placements are associated with significant risks for psychopathology. Moreover, we provide causal evidence for the long-lasting positive effect of foster care in reducing the risk of psychopathology in adolescence, especially among those in stable placements. These results provide strong evidence that early and stable placements into quality foster care may mitigate risk for psychopathology following severe early psychosocial deprivation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

OBJECTIVEUnexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion.METHODSThe electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors.RESULTSA total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001).CONCLUSIONSIncreased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.

To determine the effectiveness of ultrasound/phonophoresis as an adjuvant to exercise or manual therapy for the improvement of patient-centred outcomes in adults with non-specific neck pain (NSNP).Seven electronic databases were systematically searched up to September 2020. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to judge the Quality of Evidence (QoE).Six studies involving 249 participants were included. The QoE was very low GRADE. Phonophoresis with capsaicin plus exercise improved pain at immediate post-treatment (MD: -3.30 [-4.05, -2.55]) but not with diclofenac sodium plus exercise as compared to exercise. Continuous ultrasound (CUS) plus exercise improved pain and pressure pain threshold (PPT) at immediate post-treatment (pain: MD: -3.42 [-4.08, -2.7]); (PPT: MD: 0.91 [0.68, 1.14]) and at intermediate-term as compared to exercise. CUS or high power pain threshold (HPPT) ultrasound plus manual therapy and exercise showed no benefit for pain reduction (MD: -0.75 [-2.08, 0.58]) did not improve function/disability (MD: -1.05 [-4.27, 2.17]) at immediate or short-term as compared to manual therapy and exercise.Due to high risk of bias, inconsistency, and indirectness the QoE is very low in support of benefit of ultrasound/phonophoresis as an adjuvant treatment for NSNP.Implication for rehabilitationDue to high risk of bias, inconsistency, and indirectness the quality of evidence (QoE) is very low in support of benefit of adding ultrasound or phonophoresis to exercise or manual therapy for pain reduction or improvement in function/disability for those with sub-acute and chronic myofascial associated neck pain. However, our confidence in the findings is very low and conclusions are likely to change as more evidences emerges.Clinicians using ultrasound therapy as an adjuvant intervention for management of chronic myofascial associated neck pain should carefully consider the available evidence on ultrasound, including the benefits and costs involved.

Objective:Incidental learning and memory, as well as processing speed, were examined in human immunodeficiency virus (HIV)-positive adults and a seronegative control group.Methods:Participants completed a computerized Symbol-Digit Modalities Test (cSDMT) with two blocked conditions: a set of trials with the standard symbol–digit pairings and the second set with a rearranged symbol–digit pairings.Results:HIV-positive adults showed slower overall reaction time compared to the HIV-negative group. More importantly, the most cognitively impaired HIV-positive group showed no interference in the rearranged set of symbol–digit pairings from the standard pairings on the cSDMT.Conclusion:The relative slowing, or interference, in the HIV-negative group and two HIV-positive groups (unimpaired and impaired) was quite large (between 122 and 131 ms). We argue that the lack of such relative slowing in the most cognitively impaired HIV-positive group indicates a deficit in incidental learning and memory.

Introduction There is limited data in the scientific literature using quantitative methods to assess response of golfer's cramp to intervention. The objective of this pilot study was to use quantitative measures to study the effect of propranolol and looking at the hole when putting. Methods 14 golfers completed 50 10’ putts (10 each x 5 conditions): two-handed looking at the ball, right hand only looking at the ball, two-handed looking at the hole, then following a single 10 mg oral dose of propranolol two-handed and right hand only putts looking at the ball. Quantitative measurements of putter movement and surface EMG to assess wrist muscle co-contraction were measured. Results Based on video review of the putting, five golfers with dystonic golfer's cramp and nine with non-dystonic yips were compared. Those with dystonic golfer's cramp had more putts with the yips and yips with co-contraction when two-handed putting looking at the ball, no increase when putting right hand only, less smoothness of putter movement, and all of these improved following propranolol and when looking at the hole. The non-dystonic group had an increase in yipped putts and yipped putts with co-contraction putting right hand only and no improvement with either intervention. Conclusion Yipped putts with co-contraction, right hand only putting, and smoothness of putter movement differed between dystonic golfer's cramp and non-dystonic yips. Propranolol and looking at the hole only improved dystonic golfer's cramp putting. This is the first pilot study of oral medication treatment for this task-specific dystonia.

ObjectiveTo update data for diagnostic accuracy of a clinical diagnosis of Parkinson disease (PD) using neuropathologic diagnosis as the gold standard.MethodsData from the Arizona Study of Aging and Neurodegenerative Disorders (AZSAND) were used to determine the predictive value of a clinical PD diagnosis. Two clinical diagnostic confidence levels were used, possible PD (PossPD, never treated or not responsive) and probable PD (ProbPD, 2/3 cardinal clinical signs and responsive to dopaminergic medications). Neuropathologic diagnosis was the gold standard.ResultsBased on the first visit to AZSAND, 15/54 (27.8%) PossPD participants and 138/163 (84.7%) ProbPD participants had confirmed PD. PD was confirmed in 24/34 (70.6%) ProbPD with ConclusionsThis updated study confirmed lower clinical diagnostic accuracy for elderly, untreated or poorly responsive PossPD participants and for ProbPD with Classification of EvidenceThis study provides Class II evidence that a clinical diagnosis of ProbPD at the first visit identifies participants who will have pathologically confirmed PD with a sensitivity of 82.6% and a specificity of 86.0%.

Objectives This study aimed to assess the feasibility, efficacy, and safety of a novel percutaneous postprocedure closure technique for large arterial sheath removal with the use of two Perclose ProGlide (Abbott Vascular Devices, Redwood City, CA) devices. Background Postprocedural closing of large-bore arteriotomies using the Perclose system can be difficult given the subsequent inability of the device to capture sufficient wall tissue. Methods Our study was a single-center retrospective analysis of 22 consecutive patients who underwent large arteriotomy closure via the postclosure technique with a 12-16-Fr sheath. Efficacy endpoints included successful deployment of the system and hemostasis. Safety endpoints included the incidence of major or minor vascular complications as defined by the Vascular Academic Research Consortium-2 (VARC-2) definitions at 30-day follow-up. Results The postclosure technique resulted in 100% technical success rate and no postprocedural bleeding or vascular complications. Conclusion Postclosure technique is a safe, highly effective, and feasible percutaneous method to achieve large-bore arteriotomy hemostasis with low rates of major bleeding or vascular complications and favorable early outcome.

BACKGROUND Plastic surgery education consists of technical skills, surgical decision-making, and the knowledge necessary to provide safe patient care. Competency in these modalities is ensured by requiring case minimums and oral and written examinations. However, there is a paucity of information detailing what teaching modalities residency programs use outside of the operating room. METHODS A 16-question survey was sent to all integrated and independent program directors. Information regarding nonsurgical resident education was collected and analyzed. RESULTS There were 44 responses (46 percent). Most programs had six to 10 faculty (43 percent), and a majority (85 percent) required faculty to participate in resident education outside of the operating room. Residents most commonly had 3 to 4 hours (43 percent) of protected educational time 1 day per week (53 percent). Nonsurgical education consisted of weekly lectures by attending physicians (44 percent) and residents (54 percent), in addition to weekly CoreQuest (48 percent), teaching rounds (38 percent), and Plastic Surgery Education Network lectures (55 percent). Monthly activities included morbidity and mortality conference (81 percent) and journal club (86 percent). Indications conference was either monthly (41 percent) or weekly (39 percent). Cadaver laboratories, visiting professors, board preparation, in-service review, and meetings with the program director occurred yearly or several times per year. Forty-nine percent of programs sponsor one educational course per resident. In addition, most programs (65 percent) do not receive outside funding for education. CONCLUSIONS These findings improve understanding of the current state of nonsurgical resident education in plastic surgery. They illustrate that residents participate in a diverse number of nonsurgical educational activities without any significant standardization.

The following position statement forms part of a response to the current concerns regarding use of mesh to perform rectal prolapse surgery. It highlights the actions being pursued by the Pelvic Floor Society (TPFS) regarding clinical governance in relation to ventral mesh rectopexy (VMR). The following are summary recommendations. Available evidence suggests that mesh morbidity for VMR is far lower than that seen in transvaginal procedures (the main subject of current concern) and lower than that observed following other abdomino‐pelvic procedures for urogenital prolapse, e.g. laparoscopic sacrocolpopexy.VMR should be performed by adequately trained surgeons who work within a multidisciplinary team (MDT) framework. Within this, it is mandatory to discuss all patients considered for surgery at an MDT meeting.Clinical outcomes of surgery and any complications resulting from surgery should be recorded in the TPFS‐hosted national database (registry) available for this purpose; in addition, all patients should be considered for entry into ongoing and planned UK/European randomized studies where this is feasible.A move towards accreditation of UK units performing VMR will improve performance and outcomes in the long term.An enhanced programme of training including staged porcine, cadaveric and preceptorship sessions will ensure the competence of surgeons undertaking VMR.Enhanced consent forms and patient information booklets are being developed, and these will help both surgeons and patients.There is weak observational evidence that technical aspects of the procedure can be optimized to reduce morbidity rates. Suture material choice may contribute towards morbidity. The available evidence is insufficient to support the use of one mesh over another (biologic vs synthetic); however, the use of polyester mesh is associated with increased morbidity.

BACKGROUND Retrograde autologous priming (RAP) before cardiopulmonary bypass (CPB) may minimize allogeneic red cell transfusion. We conducted a systematic review of the literature to examine the impact of RAP on perioperative allogeneic red cell transfusions in cardiac surgical patients. METHODS This study involved a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies evaluating the use of RAP in cardiac surgery involving CPB. The primary outcome was intraoperative allogeneic red cell transfusion. Secondary outcomes included whole hospital allogeneic transfusions and adverse events such as acute kidney injury (AKI) and stroke. RESULTS A total of 11 RCTs (n = 1337 patients) were included, comparing RAP patients (n = 674) to control (n = 663). In addition, 10 observational studies (n = 2327) were included, comparing RAP patients (n = 1257) to control (n = 1070). Overall, RAP was associated with a significantly reduced incidence of intraoperative red cell transfusion (n = 18 studies; odds ratio [OR] = 0.34; 95% confidence interval [CI], 0.22-0.55, P < .001) compared to controls. This effect was seen among RCTs (n = 10 studies; OR = 0.19; 95% CI, 0.08-0.45, P < .001) and observational studies (n = 8 studies; OR = 0.66; 95% CI, 0.50-0.87, P = .004) in isolation. RAP was also associated with a significantly reduced incidence of whole hospital red cell transfusion (n = 5 studies; OR = 0.28; 95% CI, 0.19-0.41, P < .001). Among the studies that reported AKI and stroke outcomes, there was no statistically significant increased odds of AKI or stroke in either RAP or control patients. CONCLUSIONS Based on the pooled results of the available literature, RAP is associated with a significant reduction in intraoperative and whole hospital allogeneic red cell transfusion. Use of RAP may prevent hemodilution of cardiac surgical patients and thus, lessen transfusions. Additional high-quality prospective studies are necessary to determine the ideal priming volume necessary to confer the greatest benefit without incurring organ injury.

Bowel dysfunction after chronic spinal cord injury (SCI) is a common source of morbidity and rehospitalization. Typical complications include constipation, fecal impaction, incontinence, abdominal distention, autonomic dysreflexia, and the necessity of interventions (i.e., suppositories, digital stimulation) to defecate. Numerous surveys have confirmed that the remediation of bowel complications is more highly valued for quality of life than improvements in walking. Much of what is known about bowel function after SCI for diagnosis and research in humans has been gained using anorectal manometry (ARM) procedures. However, ARM has been underutilized in pre-clinical animal work. Therefore, a novel combination of outcome measures was examined in the current study that incorporates functional output of the bowel (weekly fecal measurements), weight gain (pre-injury to terminal weight), and terminal ARM measurement with external anal sphincter electromyography under urethane anesthesia. The results indicate higher fecal output after contusion during the sub-acute period (4-7 days) post-injury, changes in the composition of the feces, and functionally obstructive responses in a specific section of the rectum (increased baseline pressure, increased frequency of contraction, and reduced ability to trigger a giant contraction to a distension stimulus). These results demonstrate significant bowel dysfunction in the rodent SCI contusion model that is consistent with data from human research. Thus, the combined measurement protocol enables the detection of changes and can be used, with minimal cost, to assess effectiveness of therapeutic interventions on bowel complications.

This study evaluated intradialytic cerebral hemodynamics measured by transcranial Doppler (TCD) in intermittent hemodialysis (iHD) versus nightly peritoneal dialysis (NIPD). Intradialytic TCD was serially performed in chronic dialysis patients receiving iHD ( n = 10) and NIPD ( n = 10). A linear mixed model was used to model mean flow velocity (MFV), pulsatility index (PI), and mean arterial pressure (MAP) as functions of time and treatment group. Intradialytic cerebral volatility (IDCV) was calculated using the coefficient of variation (CV) and mean absolute value of change (AVC) of each patient’s MFV, PI, and MAP values over time. Mixed model analyses found no significant difference between MFV, PI, and MAP treatment groups in change over time, though volatility differed significantly. Mean CV values for MFV, PI, and MAP were higher in iHD than NIPD (MFV 0.22 vs. 0.10, p = 0.005; PI 0.14 vs. 0.08, p = 0.003; MAP 0.057 vs. 0.032, p = 0.009). AVC values were similarly higher in iHD compared to NIPD (MFV 8.26 vs. 4.43, p = 0.04; PI 0.17 vs. 0.084, p < 0.001; MAP 6.05 vs. 2.9, p = 0.003). PI, MFV, and MAP were more stable in NIPD than iHD, as measured by intradialytic TCD monitoring. This study identifies IDCV as a unique TCD metric for intradialytic cerebral hemodynamics.

The COVID-19 pandemic is among the deadliest infectious diseases to have emerged in recent history. As with all past pandemics, the specific mechanism of its emergence in humans remains unknown. Nevertheless, a large body of virologic, epidemiologic, veterinary, and ecologic data establishes that the new virus, SARS-CoV-2, evolved directly or indirectly from a β-coronavirus in the sarbecovirus (SARS-like virus) group that naturally infect bats and pangolins in Asia and Southeast Asia. Scientists have warned for decades that such sarbecoviruses are poised to emerge again and again, identified risk factors, and argued for enhanced pandemic prevention and control efforts. Unfortunately, few such preventive actions were taken resulting in the latest coronavirus emergence detected in late 2019 which quickly spread pandemically. The risk of similar coronavirus outbreaks in the future remains high. In addition to controlling the COVID-19 pandemic, we must undertake vigorous scientific, public health, and societal actions, including significantly increased funding for basic and applied research addressing disease emergence, to prevent this tragic history from repeating itself.

Background Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review. Methods We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI. Results We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21–30, I2 = 91 %), and 19 % experienced anal incontinence (95 %CI, 14–25, I2 = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10–17, I2 = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6–24, I2 = 95 %). Following primary repair of OASIS, 55 % (46–63, I2 = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33–43, I2 = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17−6.45, I2 = 98 %). Interpretation Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.

Background and purpose Patients with acute ischemic stroke receive computed tomography angiogram (CTA) and digital subtraction angiogram (DSA) for clinical evaluation. Current guidelines lack in defining indications for transcranial Doppler (TCD) and/or carotid duplex ultrasonography (CUS) in acute stroke evaluation or follow-up cerebrovascular imaging after reperfusion. We investigated the clinical utility of performing additional TCD/CUS after reperfusion in guiding postacute care stroke management. Methods Retrospective review of acute ischemic stroke patients admitted to a comprehensive stroke center with CTA head and neck and/or DSA followed by TCD/CUS. Cases were reviewed by two authors to determine if TCD/CUS provided additional diagnostic information to aid management. A nominal group process, using a third author, achieved consensus in cases of disagreements. Results Only 25 of 198 patients had CTA or DSA followed by TCD/CUS. Ten (40%) cases showed new clinical information from CUS aiding management. Of those with TCD, 5 patients (22.7%) had findings that impacted management. These clinical scenarios included detection of mobile thrombus requiring anticoagulation; distinguishing carotid near-occlusion from occlusion; confirming hemodynamic significance of intra/extracranial stenosis helping emergent stenting/endarterectomy; detecting hyperperfusion on TCDs causing symptoms; and establishing chronicity of carotid stenosis based on collateral flow patterns, which deferred further intervention. Discussion Our experience shows that TCD/CUS may offer additional diagnostic information assisting postacute care management in small subset of patients with acute ischemic stroke. Larger studies are needed to research the clinical impact and cost-effectiveness of additional imaging and inform clinical guidelines for selecting patients who will benefit from these additional studies.