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Background and purposeTo assess whether initial imaging characteristics independently predict 1-year neurological outcomes in childhood arterial ischemic stroke patients.MethodsWe used prospectively collected demographic and clinical data, imaging data, and 1-year outcomes from the VIPS study (Vascular Effects of Infection in Pediatric Stroke). In 288 patients with first-time stroke, we measured infarct volume and location on the acute magnetic resonance imaging studies and hemorrhagic transformation on brain imaging studies during the acute presentation. Neurological outcome was assessed with the Pediatric Stroke Outcome Measure. We used univariate and multivariable ordinal logistic regression models to test the association between imaging characteristics and outcome.ResultsUnivariate analysis demonstrated that infarcts involving uncinate fasciculus, angular gyrus, insular cortex, or that extended from cortex to the subcortical nuclei were significantly associated with poorer outcomes with odds ratios ranging from 1.95 to 3.95. All locations except the insular cortex remained significant predictors of poor outcome on multivariable analysis. When infarct volume was added to the model, the locations did not remain significant. Larger infarct volumes and younger age at stroke onset were significantly associated with poorer outcome, but the strength of the relationships was weak. Hemorrhagic transformation did not predict outcome.ConclusionsIn the largest pediatric arterial ischemic stroke cohort collected to date, we showed that larger infarct volume and younger age at stroke were associated with poorer outcomes. We made the novel observation that the strength of these associations was modest and limits the ability to use these characteristics to predict outcome in children. Infarcts affecting specific locations were significantly associated with poorer outcomes in univariate and multivariable analyses but lost significance when adjusted for infarct volume. Our findings suggest that infarcts that disrupt critical networks have a disproportionate impact upon outcome after childhood arterial ischemic stroke.

Background and purposeArteriopathy is the leading cause of childhood arterial ischemic stroke. Mechanisms are poorly understood but may include inherent abnormalities of arterial structure. Extracranial dissection is associated with connective tissue disorders in adult stroke. Focal cerebral arteriopathy is a common syndrome where pathophysiology is unknown but may include intracranial dissection or transient cerebral arteriopathy. We aimed to quantify cerebral arterial tortuosity in childhood arterial ischemic stroke, hypothesizing increased tortuosity in dissection.MethodsChildren (1 month to 18 years) with arterial ischemic stroke were recruited within the Vascular Effects of Infection in Pediatric Stroke (VIPS) study with controls from the Calgary Pediatric Stroke Program. Objective, multi-investigator review defined diagnostic categories. A validated imaging software method calculated the mean arterial tortuosity of the major cerebral arteries using 3-dimensional time-of-flight magnetic resonance angiographic source images. Tortuosity of unaffected vessels was compared between children with dissection, transient cerebral arteriopathy, meningitis, moyamoya, cardioembolic strokes, and controls (ANOVA and post hoc Tukey). Trauma-related versus spontaneous dissection was compared (Student t test).ResultsOne hundred fifteen children were studied (median, 6.8 years; 43% women). Age and sex were similar across groups. Tortuosity means and variances were consistent with validation studies. Tortuosity in controls (1.346±0.074; n=15) was comparable with moyamoya (1.324±0.038; n=15; P=0.998), meningitis (1.348±0.052; n=11; P=0.989), and cardioembolic (1.379±0.056; n=27; P=0.190) cases. Tortuosity was higher in both extracranial dissection (1.404±0.084; n=22; P=0.021) and transient cerebral arteriopathy (1.390±0.040; n=27; P=0.001) children. Tortuosity was not different between traumatic versus spontaneous dissections (P=0.70).ConclusionsIn children with dissection and transient cerebral arteriopathy, cerebral arteries demonstrate increased tortuosity. Quantified arterial tortuosity may represent a clinically relevant imaging biomarker of vascular biology in pediatric stroke.

Background and purposeAlthough arteriopathies are the most common cause of childhood arterial ischemic stroke, and the strongest predictor of recurrent stroke, they are difficult to diagnose. We studied the role of clinical data and follow-up imaging in diagnosing cerebral and cervical arteriopathy in children with arterial ischemic stroke.MethodsVascular effects of infection in pediatric stroke, an international prospective study, enrolled 355 cases of arterial ischemic stroke (age, 29 days to 18 years) at 39 centers. A neuroradiologist and stroke neurologist independently reviewed vascular imaging of the brain (mandatory for inclusion) and neck to establish a diagnosis of arteriopathy (definite, possible, or absent) in 3 steps: (1) baseline imaging alone; (2) plus clinical data; (3) plus follow-up imaging. A 4-person committee, including a second neuroradiologist and stroke neurologist, adjudicated disagreements. Using the final diagnosis as the gold standard, we calculated the sensitivity and specificity of each step.ResultsCases were aged median 7.6 years (interquartile range, 2.8-14 years); 56% boys. The majority (52%) was previously healthy; 41% had follow-up vascular imaging. Only 56 (16%) required adjudication. The gold standard diagnosis was definite arteriopathy in 127 (36%), possible in 34 (9.6%), and absent in 194 (55%). Sensitivity was 79% at step 1, 90% at step 2, and 94% at step 3; specificity was high throughout (99%, 100%, and 100%), as was agreement between reviewers (κ=0.77, 0.81, and 0.78).ConclusionsClinical data and follow-up imaging help, yet uncertainty in the diagnosis of childhood arteriopathy remains. This presents a challenge to better understanding the mechanisms underlying these arteriopathies and designing strategies for prevention of childhood arterial ischemic stroke.

Alice Kit Ying Chan, Yiu Cheung Tsang, Chun Hung Chu, Chiu Shun Peter Tsang Faculty of Dentistry, University of Hong Kong, Prince Philip Dental Hospital, Hong Kong Special Administrative Region of the People’s Republic of ChinaCorrespondence: Chiu Shun Peter TsangFaculty of Dentistry, University of Hong Kong, Prince Philip Dental Hospital, 34 Hospital Road, Hong Kong Special Administrative Region of the People’s Republic of ChinaTel +852-2859-0310Fax +852-2858-6144Email csptsang@hku.hkBackground: The antibiotic lock technique (ALT) has been recommended for the prevention and treatment of catheter-related candidaemia. Biofilms of Candida species are resistant to some of the antifungal agents currently used. Aspirin has been shown to have anti-fungal effect but its effect on candidal biofilm is poorly understood.Purpose: The aim of the current study was to evaluate the anti-biofilm effect of aspirin on Candida biofilms including C. albicans, C. glabrata, C. krusei and C. tropicalis formed on surgical catheters and the concentration and time required to eradicate the biofilms.Methods: Biofilms of Candida species were grown on silicone catheters and incubated in aspirin at different concentrations for 2, 4 and 24 hours. The biofilms remaining were then determined quantitatively by colony-forming unit (CFU) counts and XTT assays.Results: The results demonstrated that among the tested Candida species, C. albicans was the most sensitive species towards aspirin. Aspirin at a concentration of 40 mg/mL in 4 hours was effective in eradicating the biofilm. For all the other tested species, they were eradicated by aspirin at a concentration of 40 mg/mL in 24 hours.Conclusion: Our results showed that aspirin may be used as an anti-fungal agent in lock therapy in the treatment of catheter-related candidaemia.Keywords: Candida species, lock therapy, antifungal, aspirin, catheter-related infection

Leung Li,1 Stephen L Chan,1 Frankie Mo,1 Edwin P Hui,1 Jane Koh,1 Allen KC Chan,2 Nelson LS Tang,2 Kit F Lee,3 Paul BS Lai,3 Simon CH Yu,4 Winnie Yeo1 1Department of Clinical Oncology, Prince of Wales Hospital, Faculty of Medicine, Hong Kong Cancer Institute, State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR; 2Department of Chemical Pathology, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR; 3Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR; 4Department of Diagnostic and Interventional Radiology, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR Purpose: Health-related quality of life (HRQoL) is a significant prognostic factor for overall survival in hepatocellular carcinoma (HCC) patients, and this is independent of stage and liver function. Inflammation plays a significant role in HCC development and progression. It was hypothesized that the inflammatory status of HCC patients may affect their HRQoL. The relationship between HRQoL and inflammatory status was explored using indicators IL-8 level and modified inflammation-based index (mIBI, based on IL-8, C-reactive protein, and albumin). Methods: From 2007–2011, HCC patients were enrolled prospectively. Baseline HRQoL assessment utilized the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-HCC18; clinical and laboratory data were collected at diagnosis. Two summary indices, C30 and HCC18 index-scores, were calculated. Correlation analyses were performed between HRQoL and inflammatory markers. Results: In the 445 patients studied, significant correlations were found between IL-8 levels and EORTC QLQ-C30, QLQ-HCC18, C30, and HCC18 index-scores. The strongest correlated factors were those reflective of constitutional symptoms, namely QLQ-C30 “appetite loss” (with Pearson’s correlation coefficient, r=0.322, P

Objective: To examine trends in microvascular complications in adolescents with type 1 diabetes between 1990 and 2009 in Sydney, Australia.Research Design and Methods: We used analysis of complications in 1,604 adolescents (54% female, aged 12-20 years, median duration 8.6 years), stratified by four time periods using Generalized Estimation Equations as follows: T1 (1990-1994), T2 (1995-1999), T3 (2000-2004), and T4 (2005-2009). Early retinopathy was detected using seven-field fundal photography, albumin excretion rate (AER) using timed overnight urine collections, and albumin-to-creatinine ratio (ACR) and peripheral nerve function using thermal and vibration threshold.Results: Retinopathy declined (53, 38, 23, and 12%; P < 0.001), as did borderline elevation of AER/ACR (45, 30, 26, and 30%; P < 0.001) and microalbuminuria (8, 4, 3, and 3%; P = 0.006). Multiple daily injections (MDI)/continuous subcutaneous insulin infusion (CSII) use increased (17, 54, 75, and 88%; P < 0.001), median HbA(1c) decreased (9.1, 8.9, 8.5, and 8.5%; P < 0.001), and severe hypoglycemia was unchanged (6, 8, 10, and 7%; P = 0.272). Retinopathy was associated with diabetes duration (odds ratio [OR] 1.12 [95% CI 1.08-1.17]), age (1.13 [1.06-1.20]), HbA(1c) (1.16 [1.08-1.25]), systolic blood pressure (BP) SDS (1.31 [1.16-1.48]), socioeconomic disadvantage (1.42 [1.04-1.95]), and 1 to 2 injections per day (vs. MDI/CSII; 1.35 [1.05-1.73]); borderline AER/ACR with male sex (1.32 [1.02-1.70]), age (1.19 [1.12-1.26]), HbA(1c) (1.18 [1.08-1.29]), weight SDS (1.31 [1.21-1.53]), insulin dose per kilograms (1.64 [1.13-2.39]), 1 to 2 injections per day (1.41 [1.08-1.84]), and socioeconomic disadvantage (1.68 [1.23-2.31]); and microalbuminuria with age (1.14 [1.01-1.29]), HbA(1c) (1.20 [1.05-1.37]), diastolic BP SDS (1.76 [1.26-2.46]), and 1 to 2 injections per day (1.95 [1.11-3.41]).Conclusions: The decline in retinopathy supports contemporary guidelines that recommend lower glycemic targets and use of MDI/CSII in children and adolescents with type 1 diabetes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe the natural history and risk factors for persistent microalbuminuria in children and adolescents with type 1 diabetes followed for up to 15 years. RESEARCH DESIGN AND METHODS: This study contained a longitudinal cohort of 972 patients; analysis of baseline risk factors was performed using logistic regression and predictors over time using survival analysis. Albumin excretion rate was measured on three consecutive timed overnight urine collections on at least two occasions. Normoalbuminuria was defined as a median albumin excretion rate < 7.5 microg/min, borderline microalbuminuria as 7.5-20 microg/min, and microalbuminuria as 20-200 microg/min. Microalbuminuria was further classified as persistent if its duration was >12 months. Median age was 12.7 years (interquartile range 11.5-14.4) and diabetes duration 6.5 years (4.1-9.3) at first assessment, and median follow-up was 6.2 years (range 1-15.3). RESULTS: The incidence of persistent microalbuminuria was 4.6 (95% CI 3.3-6.1) per 1,000 patient-years. Predictors of persistent microalbuminuria from the first assessment using multiple logistic regression were high cholesterol (odds ratio 2.2 [95% CI 1.2-4.0]) and borderline microalbuminuria (2.5 [1.2-5.2]). Predictors using Cox regression were HbA(1c) (hazard ratio 1.4 [95% CI 1.1-1.7]), age at diagnosis (1.2 [1.1-1.3]), obesity (3.6 [0.8-15.5]), and insulin dose (2.7 [1.0-7.5]). CONCLUSIONS: Children and adolescents with type 1 diabetes who have borderline microalbuminuria are more than twice as likely to develop persistent microalbuminuria. In addition to poor glycemic control, clinical markers of insulin resistance were associated with an increased risk of microalbuminuria. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients treated in a usual-care setting often do not comply with prescribed treatment regimens as closely as those treated in a clinical trial, for a variety of reasons. OBJECTIVES: We sought to describe compliance over 3 years with a statin treatment in an observational study in a usual-care setting and to investigate potential risk factors for poor compliance. METHODS: Enrollees in a Massachusetts health maintenance organization (HMO) who presented with baseline low-density lipoprotein cholesterol (LDL-C) > or =130 mg/dL and who started statin treatment between January 1, 1994, and July 1, 1999, were followed until death, termination of membership in the HMO, or July 1, 1999, whichever came first, as documented by the HMO's drug-dispensing electronic records. The records included information about the demographics, service dates, laboratory data, and filled prescriptions. The outcome measures were time to treatment discontinuation, time to treatment resumption, and adherence to treatment. RESULTS: A total of 4776 enrollees were included in the analysis. Most patients were aged 50 to 69 years (57%), men (52%), had LDL-C > or =160 mg/dL (77%), and received their prescription for antihyperlipidemia therapy from an internist or family physician (87%). The hazard of discontinuation was high during the first 6 months of therapy, with 20% of the initial population discontinuing treatment during this time period, then decreased, so that the fraction of continuing users leveled off: 74%, 65%, and 61% of statin initiators were still on treatment 1, 2, and 3 years after entry, respectively. The probability of resuming statin treatment was 51% within 24 months after last prescription filled. The proportion of adherent users stayed stable, between 53% and 55%, after the first 6 months. Risk factors of treatment discontinuation, treatment resumption, and adherence were remarkably similar and were stable over time. The significant predictors of treatment discontinuation were age <50 years (hazard ratio [HR], 1.45 [95% Cl, 1.26-1.68]), female sex (HR, 1.18 [95% CI, 1.06-1.30], and previous antihyperlipidemia treatment (HR, 0.71 [95% CI, 0.63-0.79]). CONCLUSIONS: In this HMO setting, women and individuals 1026 aged <50 years were at risk for poor compliance with statin therapy. Our analysis suggests that the association between compliance and age or gender may be quite stable over the first 3 years of treatment. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Our primary objective was to obtain robust estimates of the low-density lipoprotein cholesterol (LDL-C) decrease from baseline over a long period (ie, 3 years) after initiation of statin treatment in a usual-care setting. Our secondary objective was to investigate the predictors of the LDL-C time course. METHODS: We retrospectively analyzed the data for a sample of enrollees in a health maintenance organization (HMO) who started statin treatment between October 1, 1995, and December 31, 1998. Using the HMO's claims database, we examined the LDL-C change from baseline (as measured at the prescribing physicians' discretion) and computed mean estimates every 6 months up to 3 years. We investigated potential predictors of the LDL-C time course (ie, age, sex, baseline LDL-C, previous treatment, prescribing physician's specialty, and most recent treatment) with a mixed model applied to longitudinal data. This model enabled us to impute missing data for all enrollees still being followed, including those who had stopped treatment, and to discuss the robustness of our findings. We applied 2 methods of imputation, assuming either of the following: (1) data were missing at random but could be estimated from the parameters in the mixed model, or (2) LDL-C returned to the baseline value > or =15 days after treatment cessation. RESULTS: We examined data from 3193 individuals. In most cases, the statin used was fluvastatin or pravastatin. The observed mean (95% CI) LDL-C decrease from baseline widened progressively from 23.6% (23.0%-24.3%) at 6 months to 28.0% (27.1%-28.9%) at 18 months and 30.2% (28.7%-31.7%) at 36 months after treatment initiation. These results remained robust after the imputation of missing data, with mean LDL-C reduction consistently >20% at each 6-month time point during the 3 years after treatment initiation. Variations as a function of baseline characteristics were limited (demographics) or explicable by extraneous factors (baseline LDL-C). There were predictable variations as a function of the most recent treatment. CONCLUSIONS: This analysis indicates a long-term reduction in LDL-C among a sample of HMO enrollees who initiated statin treatment in a usual-care setting. The results were robust after imputation of missing data, with mean decrease from baseline consistently >20% over 3 years. However, given the retrospective design of our study and the absence of a control group, we cannot determine how much of the decrease was attributable to treatment. [ABSTRACT FROM AUTHOR]

Ken Junyang Goh,1 Anthony Chau Ang Yii,1,2 Therese Sophie Lapperre,1,2 Adrian KW Chan,1–3 Fook Tim Chew,4 Sanjay H Chotirmall,5,* Mariko Siyue Koh1–3,* 1Department of Respiratory and Critical Care Medicine, Singapore General Hospital, 2Duke-National University of Singapore Medical School, 3Allergy Centre, Singapore General Hospital, 4Department of Biological Sciences, Faculty of Science, National University of Singapore, 5Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore *These authors contributed equally to this work Background: Severe asthma is a largely heterogeneous disease with varying phenotypic profiles. The relationship between specific allergen sensitization and asthma severity, particularly in Asia, remains unclear. We aim to study the prevalence of specific allergen sensitization patterns and investigate their association with outcomes in a severe asthma cohort in an Asian setting. Methods: We conducted a cross-sectional study of patients receiving step 4 or 5 Global Initiative for Asthma treatment. Univariate and multivariate analyses were performed to assess the association between sensitization to a specific identifiable allergen by skin prick test (SPT) and uncontrolled asthma (defined in our study as the use of ≥2 steroid bursts or hospitalization in the past year, a history of near-fatal asthma or evidence of airflow obstruction on spirometry). Results: Two hundred and six severe asthma patients (mean age 45±17 years, 99 [48.1%] male) were evaluated. Of them, 78.2% had a positive SPT to one or more allergens. The most common allergen to which patients were sensitized was house dust mites (Blomia tropicalis, Dermatophagoides pteronyssinus and Dermatophagoides farinae). Also, 11.7% were sensitized to Aspergillus species. On multivariate analysis, Aspergillus sensitization was associated with uncontrolled asthma (odds ratio 6.07, 95% confidence interval 1.80–20.51). In particular, Aspergillus sensitization was independently associated with the use of ≥2 steroid bursts in the past year (odds ratio 3.05, 95% confidence interval 1.04–8.95). No similar associations of uncontrolled asthma with sensitization to any other allergens were found. Conclusion: High allergen, specifically Aspergillus sensitization was observed in the Asian population with severe asthma by SPT. Aspergillus sensitization was specifically associated with frequent exacerbations and a greater corticosteroid requirement. An improved understanding of the severe asthma with Aspergillus sensitization phenotype is warranted, which is likely a subgroup of severe asthma with fungal sensitization. Keywords: atopy, airway, fungus, Aspergillus, outcomes, prognosis

When cancerous masses are embedded in and camouflaged by varying densities of parenchymal tissue structures, they are difficult to visually detect on mammograms. We present a novel algorithm based on the discrete wavelet transform (DWT) and multiresolution markov random field (MMRF) that will single out the suspicious masses to assist the attending radiologist in making decisions. Copyright (c) 1999 by W.B. Saunders Company [ABSTRACT FROM AUTHOR]

Objective: To determine the rate and magnitude of temperature change in response to ultrasound in human patellar tendon for two treatment sizes. Design and Setting: A thermistor was inserted into the medial aspect of each subject's right patellar tendon, and the baseline temperature was recorded. Using stratified random sampling and using a transducer head with an effective radiating area (ERA) of 4.5 CM2, we had eight subjects each undergo either the 2- or 4-ERA ultrasound treatment first. Each subject received a 3-MHz continuous ultrasound treatment at 1 W/cm2 for both the 2- and 4-ERA treatment sizes. Subjects: Sixteen subjects (8 males, 21.3 +/- 1.9 years, and 8 females, 21.0 +/- 2.8 years) participated. Measurements: We moved the sound head at a speed of 2 to 3 cm/sec while recording the tendon temperature every 30 seconds during, and for 20 minutes after, the 4-minute treatment. Twenty minutes after the treatment, we applied the second treatment to the other ERA treatment size. Results: At the end of the treatment, the mean temperature increase was significantly different (P = .006) between treatment sizes (8.3 degrees C +/- 1.7 degrees C (2 x ERA) and 5.0 degrees C +/- 1.0 degrees C (4 x ERA)). The rate of increase was also significantly different (P < .001). The heating rate per minute for the 2-ERA treatment was 2.1 degrees C +/- 0.4 degrees C and 1.3 degres C +/- 0.3 degrees C for the 4-ERA treatment. There was a significant difference in the cooling between treatment sizes (P = .001). The rate of temperature decrease between treatment sizes was significantly different only during the first 5-minute interval post-treatment. Conclusion: Three-megahertz ultrasound at an intensity of 1 W/cm2 significantly increased patellar tendon temperature at both 2 and 4 x ERA, but our results confirm that the 2-ERA treatment size provided higher and longer heating than the 4-ERA treatment size. [ABSTRACT FROM AUTHOR]

Background: Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children.Methods: The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.Results: We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C).Conclusions: The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies. [ABSTRACT FROM AUTHOR]

The globus pallidus externa (GPe) is a heterogenous nucleus of the basal ganglia, with intricate connections to other basal ganglia nuclei, as well as direct connections to the cortex. The anatomic, molecular and electrophysiologic properties of cortex-projecting pallidocortical neurons are not well characterized. Here we show that pallidocortical neurons project to diverse motor and non-motor cortical regions, are organized topographically in the GPe, and segregate into two distinct electrophysiological and molecular phenotypes. In addition, we find that the GPe receives direct synaptic input back from deep layers of diverse motor and non-motor cortical regions, some of which form reciprocal connections onto pallidocortical neurons. These results demonstrate the existence of a fast, closed-loop circuit between the GPe and the cortex which is ideally positioned to integrate information about behavioral goals, internal states, and environmental cues to rapidly modulate behavior.

Study Design: Retrospective analysis of prospective multicenter adult spinal deformity (ASD) database., Objective: To determine the prevalence and prognosis of postoperative coronal malalignment following LLIF for ASD with Qiu type A coronal alignment., Summary of Background Data: Qiu Type A coronal alignment is defined as coronal vertical axis (CVA) <30mm.1 There is concern that circumferential minimally invasive surgery (cMIS) with lateral lumbar interbody fusion (LLIF) is associated with postoperative coronal malalignment in ASD with preoperative Qiu type A patients., Methods: Qui type A patients undergoing cMIS with LLIF for ASD were included, with ASD defined with at least: maximum CC≥20°, SVA>5 cm, PI-LL≥10°, or PT>20°. Two year (2Y) clinical outcomes were compared for type A with 2Y CVA≥30 mm (MAL) versus <30 mm (ALIGN) and were adjusted for factors reaching P<0.05 on univariate comparisons (age, BMI, and ODI)., Results: 43 patients met inclusion criteria, of which 12 (27.9%) developed coronal malalignment and 31 (72.1%) remained coronally aligned at 2Y. At baseline, MAL were older (73.0 vs. 69.0, P=0.045), had a lower BMI (26.09 vs. 29.45, P=0.047), and were less disabled (ODI 42.83 vs. 51.69, P=0.016). Otherwise, the groups were well-matched for baseline characteristics. At 2Y, MAL had a greater 2Y SVA (mean 54.08 vs 19.00 mm, P=0.01). Clinically, MAL was associated with inferior 2Y SF-36 PCS (34.78 vs. 37.42, adj P=0.043) and 2Y SRS-22r function/activity domain (3.03 vs. 3.36, adj P=0.040), but otherwise similar in other patient-reported-outcome-metrics (adj P>0.05 for all). 2Y complications were similar between groups, including for reoperations and major and minor complications (adj P>0.05 for all)., Conclusions: In Qui type A patients undergoing cMIS with LLIF for ASD, 27.9% develop coronal malalignment, which was associated with worse SF-36 PCS and SRS-22r function/activity. Despite radiographic malalignment, malalignment was not associated with higher 2-year complication rates including reoperations., Competing Interests: There is no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: The authors report current 3-year and 5-year institutional bibliometric profiles and investigate the correlations between objective metrics of neurosurgical residency programs and social media presence, including residency program size, faculty count, Doximity rankings, and measures of research output., Methods: A list of neurosurgery residency programs was obtained through the Doximity Residency Navigator. Publication history of faculty members was compiled using Scopus and analyzed to create institutional bibliometric profiles from 2018-2022 to 2020-2022. Mann-Whitney U tests were used to compare departmental metrics for institutions with and without social media accounts. Spearman rank correlations were used to examine the relationship between social media following and metrics, and between Twitter following and methods of Twitter use., Results: 74% (n = 86) of neurosurgery programs have a Twitter account, 47% (n = 55) have a Facebook account, 63% (n = 73) have Instagram accounts, and 16% (n = 19) have LinkedIn accounts. The most notable differences were found when comparing departments with and without Twitter accounts, where a difference was found in all metrics except the average H-index. Residency program size, faculty count, average H-index, 3-year and 5-year publication and citation counts per faculty, and institutional H-indices were significantly correlated with Twitter following. Higher Doximity rankings were correlated with Twitter following and Facebook likes. There is a greater increase in 5-year citations per publication from 2009-2013 to 2018-2022 for institutions that created departmental Twitter accounts after 2013. Articles that were tweeted about had higher 3-year citations per publication than the institution's overall 3-year citations per publication., Conclusion: Our findings provide updated insight into the relationship between social media presence and objective academic metrics of neurosurgery departments. We identify and quantify correlations between social media platforms and program characteristics, with a focus on research output. These metrics can be used to guide programs in their development of social media., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Summary of Background Data: Although pseudoangina is most commonly caused by cervical disc herniation, several cases have been described where thoracic herniation produced symptoms of pseudoangina. If thoracic herniation can produce angina-like pain, then it is important to consider whether pathology of the thoracolumbar spine, in general, can trigger false pain syndromes distinct from pseudoangina., Objective: We seek to provide the most comprehensive study regarding the diagnosis and treatment of spinal conditions causing false pain syndromes., Study Design: Systematic review of the current literature using PRISMA 2020 recommendations., Methods: We queried the literature and systematically selected relevant studies according to PRISMA guidelines., Results: Across 22 selected studies, the sample size was 30 patients, and a total of 26 met the criteria for statistical analysis. Seven (26.9%) of these patients presented with a chief complaint of pseudoangina resulting from thoracic disc herniation. 73.1% (19/26) of patients exhibited pain mimicking visceral origin. Overall, 13/19 (68.4%) patients exhibited thoracic spine disease only and 4/19 (21.1%) patients were affected at lumbar levels only, while 2 (10.5%) patients exhibited thoracolumbar herniation. Presentations included abdominal pain (11/19) mimicking appendicitis or pancreatitis, flank pain mimicking renal colic (8/19), and 2 cases of scrotal pain/orchalgia. Symptom durations ranged from acute (<24 h) to 7 years. Treatments were reported for 18/19 patients and all treated patients reported alleviated pain. Seven out of 18 patients were managed conservatively while 11/18 were treated surgically. Misdiagnosis resulted in unnecessary surgery (pancreaticojejunostomy) or other invasive procedures., Conclusions: In spinal disorders manifesting with atypical pain syndromes, delay in proper diagnosis and unnecessary treatments can, unfortunately, cause prolonged patient suffering and increased cost of health care. As a result, some have proposed that spinal screening should be incorporated into clinical examinations involving false pain syndromes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Practice on fasting prior to extubation in critically ill patients is variable. Efficacy of fasting in reducing gastric volume has not been well established. The primary objective of this study was to assess the effect of 4 h of fasting on prevalence of empty stomach using gastric ultrasonography in critically ill subjects who are fasted for extubation. The secondary objectives were to evaluate the change in gastric volumes during 4 h of fasting and to determine factors associated with empty stomach after fasting., Methods: This was a single-center, prospective, observational study on adult ICU subjects who were enterally fed for at least 6 h continuously and mechanically ventilated. Gastric ultrasound was performed immediately prior to commencement of fasting, after 4 h of fasting, and after nasogastric (NG) aspiration after 4 h of fasting. An empty stomach was defined as a gastric volume ≤ 1.5 mL/kg., Results: Forty subjects were recruited, and 38 (95%) had images suitable for analysis. The prevalence of empty stomach increased after 4 h of fasting (25 [65.8%] vs 31 [81.6%], P = .041) and after 4 h of fasting with NG aspiration (25 [65.8%] vs 34 [89.5%], P = .008). There was a significant difference in median (interquartile range) gastric volume per body weight between before fasting and 4 h after fasting (1.0 [0.5-1.8] mL/kg vs 0.4 [0.2-1.0] mL/kg, P < .001). No patient factors were associated with higher prevalence of empty stomach after 4 h of fasting., Conclusions: Most mechanically ventilated subjects had empty stomachs prior to fasting for extubation. Fasting for 4 h further increased the prevalence of empty stomach at extubation to > 80%., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Competing Interests: Conflict of interest: none declared.

Objective: Some patients treated surgically for grade 1 spondylolisthesis require revision surgery. Outcomes after revision surgery are not well studied. The objective of this study was to determine how revision surgery impacts patient-reported outcomes (PROs) in patients undergoing decompression only or decompression and fusion (D+F) for grade 1 spondylolisthesis within 5 years of the index surgery., Methods: Patients in the 12 highest Quality Outcomes Database (QOD) enrolling sites with a diagnosis of grade 1 spondylolisthesis were identified and the incidence of revision surgery between the decompression-only and D+F patients were compared. PROs were compared between cohorts requiring revision surgery versus a single index procedure., Results: Of 608 patients enrolled, 409 had complete 5-year data available for this study. Eleven (13.3%) of 83 patients underwent revision in the decompression-only group as well as 32 (9.8%) of 326 in the D+F group. For the entire cohort, patients requiring revision had significantly worse PROs at 5 years: Oswestry Disability Index (ODI) 27.4 versus 19.4, p = 0.008; numeric rating scale for back pain (NRS-BP) 4.1 versus 3.0, p = 0.013; and NRS for leg pain (NRS-LP) 3.4 versus 2.1, p = 0.029. In the decompression-only group, the change in 5-year PROs was not impacted by revision status: ODI 31.9 versus 24.2, p = 0.287; NRS-BP 1.9 versus 2.9, p = 0.325; and NRS-LP 6.2 versus 3.7, p = 0.011. In the D+F group, the change in 5-year PROs was diminished if patients required revision: ODI 19.1 versus 29.1, p = 0.001; NRS-BP 3.0 versus 4.0, p = 0.170; and NRS-LP 2.3 versus 4.6, p = 0.001., Conclusions: The most common reasons for reoperation within 5 years in the decompression-only group were repeat decompression and instability, whereas in the D+F group the most common reason was adjacent-segment disease. The need for revision resulted in modestly diminished benefit compared with patients with no revisions. These differences were greater in the fusion cohort compared with the decompression-only cohort. The mean PRO improvement still far exceeded minimal clinically important difference thresholds for all measures for patients who underwent a revision surgery.

BackgroundLate outbreak identification is a common risk factor mentioned in case reports of large respiratory infection outbreaks in long-term care (LTC) homes.AimTo systematically measure the association between late SARS-CoV-2 outbreak identification and secondary SARS-CoV-2 infection and mortality in residents of LTC homes.MethodsWe studied SARS-CoV-2 outbreaks across LTC homes in Ontario, Canada from March to November 2020, before the COVID-19 vaccine rollout. Our exposure (late outbreak identification) was based on cumulative infection pressure (the number of infectious resident-days) on the outbreak identification date (early: ≤ 2 infectious resident-days, late: ≥ 3 infectious resident-days), where the infectious window was -2 to +8 days around onset. Our outcome consisted of 30-day incidence of secondary infection and mortality, based on the proportion of at-risk residents with a laboratory-confirmed SARS-CoV-2 infection with onset within 30 days of the outbreak identification date.ResultsWe identified 632 SARS-CoV-2 outbreaks across 623 LTC homes. Of these, 36.4% (230/632) outbreaks were identified late. Outbreaks identified late had more secondary infections (10.3%; 4,437/42,953) and higher mortality (3.2%; 1,374/42,953) compared with outbreaks identified early (infections: 3.3%; 2,015/61,714; p < 0.001, mortality: 0.9%; 579/61,714; p < 0.001). After adjustment for 12 LTC home covariates, the incidence of secondary infections in outbreaks identified late was 2.90-fold larger than that of outbreaks identified early (OR: 2.90; 95% CI: 2.04-4.13).ConclusionsThe timeliness of outbreak identification could be used to predict the trajectory of an outbreak, plan outbreak measures and retrospectively provide feedback for quality improvement, with the objective of reducing the impacts of respiratory infections in LTC home residents.

Objective: The long-term effects of increased body mass index (BMI) on surgical outcomes are unknown for patients who undergo surgery for low-grade lumbar spondylolisthesis. The goal of this study was to assess long-term outcomes in obese versus nonobese patients after surgery for grade 1 spondylolisthesis., Methods: Patients who underwent surgery for grade 1 spondylolisthesis at the Quality Outcomes Database's 12 highest enrolling sites (SpineCORe group) were identified. Long-term (5-year) outcomes were compared for patients with BMI ≥ 35 versus BMI < 35., Results: In total, 608 patients (57.6% female) were included. Follow-up was 81% (excluding patients who had died) at 5 years. The BMI ≥ 35 cohort (130 patients, 21.4%) was compared to the BMI < 35 cohort (478 patients, 78.6%). At baseline, patients with BMI ≥ 35 were more likely to be younger (58.5 ± 11.4 vs 63.2 ± 12.0 years old, p < 0.001), to present with both back and leg pain (53.8% vs 37.0%, p = 0.002), and to require ambulation assistance (20.8% vs 9.2%, p < 0.001). Furthermore, the cohort with BMI ≥ 35 had worse baseline patient-reported outcomes including visual analog scale (VAS) back (7.6 ± 2.3 vs 6.5 ± 2.8, p < 0.001) and leg (7.1 ± 2.6 vs 6.4 ± 2.9, p = 0.031) pain, disability measured by the Oswestry Disability Index (ODI) (53.7 ± 15.7 vs 44.8 ± 17.0, p < 0.001), and quality of life on EuroQol-5D (EQ-5D) questionnaire (0.47 ± 0.22 vs 0.56 ± 0.22, p < 0.001). Patients with BMI ≥ 35 were more likely to undergo fusion (85.4% vs 74.7%, p = 0.01). There were no significant differences in 30- and 90-day readmission rates (p > 0.05). Five years postoperatively, there were no differences in reoperation rates or the development of adjacent-segment disease for patients in either BMI < 35 or ≥ 35 cohorts who underwent fusion (p > 0.05). On multivariate analysis, BMI ≥ 35 was a significant risk factor for not achieving minimal clinically important differences (MCIDs) for VAS leg pain (OR 0.429, 95% CI 0.209-0.876, p = 0.020), but BMI ≥ 35 was not a predictor for achieving MCID for VAS back pain, ODI, or EQ-5D at 5 years postoperatively., Conclusions: Both obese and nonobese patients benefit from surgery for grade 1 spondylolisthesis. At the 5-year time point, patients with BMI ≥ 35 have similarly low reoperation rates and achieve rates of satisfaction and MCID for back pain (but not leg pain), disability (ODI), and quality of life (EQ-5D) that are similar to those in patients with a BMI < 35.

Objective: The aim of this study was to compare the rate of achievement of the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) and satisfaction between cervical spondylotic myelopathy (CSM) patients with and without class III obesity who underwent surgery., Methods: The authors analyzed patients from the 14 highest-enrolling sites in the prospective Quality Outcomes Database CSM cohort. Patients were dichotomized based on whether or not they were obese (class III, BMI ≥ 35 kg/m2). PROs including visual analog scale (VAS) neck and arm pain, Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA), EQ-5D, and North American Spine Society patient satisfaction scores were collected at baseline and 24 months after cervical spine surgery., Results: Of the 1141 patients with CSM who underwent surgery, 230 (20.2%) were obese and 911 (79.8%) were not. The 24-month follow-up rate was 87.4% for PROs. Patients who were obese were younger (58.1 ± 12.1 years vs 61.2 ± 11.6 years, p = 0.001), more frequently female (57.4% vs 44.9%, p = 0.001), and African American (22.6% vs 13.4%, p = 0.002) and had a lower education level (high school or less: 49.1% vs 40.8%, p = 0.002) and a higher American Society of Anesthesiologists grade (2.7 ± 0.5 vs 2.5 ± 0.6, p < 0.001). Clinically at baseline, the obese group had worse neck pain (VAS score: 5.7 ± 3.2 vs 5.1 ± 3.3), arm pain (VAS score: 5.4 ± 3.5 vs 4.8 ± 3.5), disability (NDI score: 42.7 ± 20.4 vs 37.4 ± 20.7), quality of life (EQ-5D score: 0.54 ± 0.22 vs 0.56 ± 0.22), and function (mJOA score: 11.6 ± 2.8 vs 12.2 ± 2.8) (all p < 0.05). At the 24-month follow-up, however, there was no difference in the change in PROs between the two groups. Even after accounting for relevant covariates, no significant difference in achievement of MCID and satisfaction was observed between the two groups at 24 months., Conclusions: Despite the class III obese group having worse baseline clinical presentations, the two cohorts achieved similar rates of satisfaction and MCID in PROs. Class III obesity should not preclude and/or delay surgical management for patients who would otherwise benefit from surgery for CSM.