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Ending the HIV epidemic requires increased testing, diagnosis, and linkage to care. In the past 10 years, rates of HIV have increased among people with substance use disorder (SUD). HIV testing is recommended during hospitalization. Despite rising rates of infections and recommendations, HIV testing remains suboptimal. This study sought to detect differences in HIV testing by race and ethnicity in people who use drugs (PWUD) admitted to Tufts Medical Center (TuftsMC). This study is a retrospective review of hospitalized PWUD admitted from January 1, 2017 to December 31, 2020. PWUD were identified through toxicology results, medication prescribed for SUD, and nursing intake questions. The primary outcome of interest was whether an HIV test was ordered during hospitalization. The indicator of interest was race and ethnicity. Of 13,486 PWUD admitted to TuftsMC, only 10% had an HIV test ordered. Compared with White patients, Black patients [adjusted odds ratio (AOR): 0.69, 95% confidence interval (CI) (0.59-0.83)] and Hispanic patients [AOR: 0.68, 95% CI (0.55-0.84)] had decreased odds of receiving an HIV test. Our report is the first to show racial and ethnic differences in HIV testing ordering for hospitalized PWUD. Without access to harm reduction tools and expanded systems-based testing strategies, the HIV epidemic will continue and disproportionately impact minoritized communities.

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Skeletal muscle wasting is a devastating consequence of cancer that contributes to increased complications and poor survival, but is not well understood at the molecular level. Herein, we investigated the role of Myocilin (Myoc), a skeletal muscle hypertrophy-promoting protein that we showed is downregulated in multiple mouse models of cancer cachexia. Loss of Myoc alone was sufficient to induce phenotypes identified in mouse models of cancer cachexia, including muscle fiber atrophy, sarcolemmal fragility, and impaired muscle regeneration. By 18 months of age, mice deficient in Myoc showed significant skeletal muscle remodeling, characterized by increased fat and collagen deposition compared with wild-type mice, thus also supporting Myoc as a regulator of muscle quality. In cancer cachexia models, maintaining skeletal muscle expression of Myoc significantly attenuated muscle loss, while mice lacking Myoc showed enhanced muscle wasting. Furthermore, we identified the myocyte enhancer factor 2 C (MEF2C) transcription factor as a key upstream activator of Myoc whose gain of function significantly deterred cancer-induced muscle wasting and dysfunction in a preclinical model of pancreatic ductal adenocarcinoma (PDAC). Finally, compared with noncancer control patients, MYOC was significantly reduced in skeletal muscle of patients with PDAC defined as cachectic and correlated with MEF2c. These data therefore identify disruptions in MEF2c-dependent transcription of Myoc as a novel mechanism of cancer-associated muscle wasting that is similarly disrupted in muscle of patients with cachectic cancer.Significance:This work identifies a novel transcriptional mechanism that mediates skeletal muscle wasting in murine models of cancer cachexia that is disrupted in skeletal muscle of patients with cancer exhibiting cachexia.

Background Aneurysm rerupture and bilateral fixed and dilated pupils (bFDPs) typically have a poor prognosis across all age groups. The synchronous occurrence of both features in the infantile demographic has not been previously reported. Case Description We describe the near-fatal clinical course of a 7-month-old infant who experienced an acute giant aneurysm rerupture with signs of bFDPs. The patient was rapidly managed with neurosurgical intervention and has achieved a favorable outcome 1 year later. Conclusions This case highlights that survival of infants who present with intracranial aneurysmal rerupture and bFDPs is amenable to rapid neurosurgical intervention and should be remembered in clinical practice.

We report a unique case and presentation of a 77-year-old man with atrial fibrillation who presented with complex imaging features, including bifrontal cerebral hematomas that progressed to multifocal macro- and microhemorrhages, vasogenic edema, and cortical/meningeal enhancement. Cerebrospinal fluid analysis was only remarkable for a protein elevation of 65 mg/dL. Leptomeningeal vessel biopsy failed to demonstrate evidence of amyloid angiopathy but did show concentric obstructive intimal fibroplasia, suggestive of chronic venous congestion. Conventional cerebral angiography showed a Cognard type IV dural arteriovenous fistulae fed by bilateral ethmoidal arteries draining directly into ectatic cortical veins. A chronic occlusion of the anterior third of the superior sagittal sinus was also noted. The fistula was successfully surgically obliterated via an uncomplicated left frontal craniotomy approach. After rehabilitation therapy, he was discharged home with a modified Rankin Scale score of 3. Because effective treatment exists, this case underscores the importance of identifying this rare etiology of intracerebral hemorrhage and pursuing adequate workup.

Shared intentionality, or collaborative interactions in which individuals have a shared goal and must coordinate their efforts, is a core component of human interaction. However, the biological bases of shared intentionality and, specifically, the processes by which the brain adjusts to the sharing of common goals, remain largely unknown. Using functional near infrared spectroscopy (fNIRS), coordination of cerebral hemodynamic activation was found in subject pairs when completing a puzzle together in contrast to a condition in which subjects completed identical but individual puzzles (same intention without shared intentionality). Interpersonal neural coordination was also greater when completing a puzzle together compared to two control conditions including the observation of another pair completing the same puzzle task or watching a movie with a partner (shared experience). Further, permutation testing revealed that the time course of neural activation of one subject predicted that of their partner, but not that of others completing the identical puzzle in different partner sets. Results indicate unique brain-to-brain coupling specific to shared intentionality beyond what has been previously found by investigating the fundamentals of social exchange.

OBJECTIVETemporal lobectomy is a well-established treatment modality for the management of medically refractory epilepsy in appropriately selected patients. The aim of this study was to assess 30-day morbidity and mortality after temporal lobectomy in cases registered in a national database.METHODSA retrospective cohort analysis was conducted using a multiinstitutional surgical registry compiled between 2006 and 2014. The authors identified patients who underwent anterior temporal lobectomy and/or amygdalohippocampectomy for a primary diagnosis of intractable epilepsy. Univariate and multivariable analyses with regard to patient demographics, comorbidities, operative characteristics, and 30-day outcomes were applied.RESULTSA total of 216 patients were included in the study. The median age was 38 years and 46% of patients were male. The median length of stay was 3 days and the 30-day mortality rate was 1.4%. Fourteen patients (6.5%) developed at least one major complication. Return to the operating room was observed in 7 patients (3.2%). Readmission within 30 days and discharge to a location other than home were available for 2011–2014 (n = 155) and occurred in 11% and 10.3% of patients, respectively. Multivariable regression analysis revealed that increasing age was an independent predictor of discharge disposition other than home and that male sex was a significant risk factor for the development of a major complication. Interestingly, the presence of the attending neurosurgeon and a resident during the procedure was significantly associated with decreased odds of prolonged length of stay (i.e., > 75th percentile [5 days]) and discharge to a location other than home.CONCLUSIONSUsing a multiinstitutional surgical registry, 30-day outcome data after temporal lobectomy for medically intractable epilepsy demonstrates a mortality rate of 1.4%, a major complication rate of 6.5%, and a readmission rate of 11%. Temporal lobectomy is an extremely effective therapy for seizures originating there—however, surgical intervention must be weighed against its morbidity and mortality outcomes.

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

OBJECTIVEHypoplasia of the A1 segment of the anterior cerebral artery is frequently observed in patients with anterior communicating artery (ACoA) aneurysms. The effect of this anatomical variant on ACoA aneurysm morphology is not well understood.METHODSDigital subtraction angiography images were reviewed for 204 patients presenting to the authors' institution with either a ruptured or an unruptured ACoA aneurysm. The ratio of the width of the larger A1 segment to the smaller A1 segment was calculated. Patients with an A1 ratio greater than 2 were categorized as having A1 segment hypoplasia. The relationship of A1 segment hypoplasia to both patient and aneurysm characteristics was then assessed.RESULTSOf 204 patients that presented with an ACoA aneurysm, 34 (16.7%) were found to have a hypoplastic A1. Patients with A1 segment hypoplasia were less likely to have a history of smoking (44.1% vs 62.9%, p = 0.0410). ACoA aneurysms occurring in the setting of a hypoplastic A1 were also found to have a larger maximum diameter (mean 7.7 vs 6.0 mm, p = 0.0084). When considered as a continuous variable, increasing A1 ratio was associated with decreasing aneurysm dome-to-neck ratio (p = 0.0289). There was no significant difference in the prevalence of A1 segment hypoplasia between ruptured and unruptured aneurysms (18.9% vs 10.7%; p = 0.1605).CONCLUSIONSOur results suggest that a hypoplastic A1 may affect the morphology of ACoA aneurysms. In addition, the relative lack of traditional risk factors for aneurysm formation in patients with A1 segment hypoplasia argues for the importance of hemodynamic factors in the formation of ACoA aneurysms in this anatomical setting.

Split cord malformation (SCM) is a rare abnormality of notochord development. The majority of cases occur in the thoracolumbar region, with more than 30 cases of cervical SCM reported. The clinical impact of SCMs involving the cervical cord is therefore largely unknown. In addition, the concomitant finding of brainstem involvement is presumably incompatible with life in the majority of patients, resulting in a paucity of data regarding this clinical scenario. In this paper the authors present the first case, to their knowledge, of an incomplete cervical SCM involving the brainstem and discuss its clinical impact, diagnosis, and management.

OBJECTIVE With improving medical therapies for chronic conditions, elderly patients increasingly present as candidates for operative intervention for degenerative diseases of the spine. To date, there is a paucity of studies examining complications in lumbar decompression, without fusion, that include patients older than 80 years. Using a multicenter national database, the authors of this study evaluated lumbar decompression in the elderly, including octogenarians, to evaluate for associations between age and patient outcomes. METHODS The 2011–2013 American College of Surgeons' National Surgical Quality Improvement Program data set was queried for patients 65 years and older with diagnosis and procedure codes inclusive of degenerative spine disease and lumbar decompression without fusion. Morbidity and mortality within the 30-day postoperative period were the primary outcomes. Secondary outcomes of interest included unplanned readmission within 30 days or discharge to a nonhome facility. Outcomes and operative characteristics were compared using chi-square tests, Kruskal-Wallis tests, and multivariable logistic regression models. RESULTS A total of 8744 patients were identified; of these patients 4573 (52.30%) were 65 years and older. Elderly patients were stratified into 3 age categories: 85 years or older (n = 314), 75–84 years (n = 1663), and 65–74 years (n = 2596). Univariate analysis showed that, compared with age younger than 65 years, increased age was associated with the number of levels (≥ 3), readmissions within 30 days, nonhome discharge, any complication, length of stay, and blood transfusion (all p < 0.001). On multivariable analysis and with younger than 65 years as the reference, increased age was associated with any minor complication (p < 0.001; ≥ 85 years: OR 3.47, 95% CI 1.69–7.13; 75–84 years: OR 2.34, 95% CI 1.45–3.78; and 65–74 years: OR 1.44, 95% CI 0.94–2.20), as well as discharge location other than home (p < 0.001; ≥ 85 years: OR 13.59, 95% CI 9.47–19.49; 75–84 years: OR 5.64, 95% CI 4.33–7.34; and 65–74 years: OR 2.61, 95% CI 2.05–3.32). CONCLUSIONS The authors' high-powered, multicenter analysis of lumbar decompression without fusion in the elderly, specifically including patients older than 80 years, demonstrates that increased age is associated with more extensive operations, resulting in longer hospital stays, increased rates of nonhome discharge, and minor complications.

Skeletal muscle wasting is a devastating consequence of cancer that contributes to increased complications and poor survival, but is not well understood at the molecular level. Herein, we investigated the role of Myocilin (Myoc), a skeletal muscle hypertrophy-promoting protein that we showed is downregulated in multiple mouse models of cancer cachexia. Loss of Myoc alone was sufficient to induce phenotypes identified in mouse models of cancer cachexia, including muscle fiber atrophy, sarcolemmal fragility, and impaired muscle regeneration. By 18 months of age, mice deficient in Myoc showed significant skeletal muscle remodeling, characterized by increased fat and collagen deposition compared with wild-type mice, thus also supporting Myoc as a regulator of muscle quality. In cancer cachexia models, maintaining skeletal muscle expression of Myoc significantly attenuated muscle loss, while mice lacking Myoc showed enhanced muscle wasting. Furthermore, we identified the myocyte enhancer factor 2 C (MEF2C) transcription factor as a key upstream activator of Myoc whose gain of function significantly deterred cancer-induced muscle wasting and dysfunction in a preclinical model of pancreatic ductal adenocarcinoma (PDAC). Finally, compared with noncancer control patients, MYOC was significantly reduced in skeletal muscle of patients with PDAC defined as cachectic and correlated with MEF2c. These data therefore identify disruptions in MEF2c-dependent transcription of Myoc as a novel mechanism of cancer-associated muscle wasting that is similarly disrupted in muscle of patients with cachectic cancer. Significance: This work identifies a novel transcriptional mechanism that mediates skeletal muscle wasting in murine models of cancer cachexia that is disrupted in skeletal muscle of patients with cancer exhibiting cachexia.

A single level discectomy is one of the most common procedures performed by spine surgeons. While some practitioners utilize the microscope, others do not. We postulate improved visualization with an intraoperative microscope decreases complications and inferior outcomes.A multicenter surgical registry was utilized for this retrospective cohort analysis. Patients with degenerative spinal diagnoses undergoing elective single level discectomies from 2010 to 2014 were included. Univariate analysis was performed comparing demographics, patient characteristics, operative data, and outcomes for discectomies performed with and without a microscope. Multivariable logistic regression analysis was then applied to compare outcomes of micro- and macrodiscectomies.Query of the registry yielded 23,583 patients meeting inclusion criteria. On univariate analysis the microscope was used in a greater proportion of the oldest age group as well as Hispanic white patients. Patients with any functional dependency, history of congestive heart failure, chronic corticosteroid use, or anemia (hematocrit35%) also had greater proportions of microdiscectomies. Thoracic region discectomies more frequently involved use of the microscope than cervical or lumbar discectomies (25.0% vs. 16.4% and 13.0%, respectively, p0.001). Median operative time (IQR) was increased in microscope cases [80min (60, 108) vs. 74min (54, 102), p0.001]. Of the patients that required reoperation within 30days, 2.5% of them had undergone a microdiscectomy compared to 1.9% who had undergone a macrodiscectomy, p=0.044. On multivariable analysis, microdiscectomies were more likely to have an operative time in the top quartile of discectomy operative times, ≥103min (OR 1.256, 95% CI 1.151-1.371, p0.001). In regards to other multivariable outcome models for any complication, surgical site infection, dural tears, reoperation, and readmission, no significant association with microdiscectomy was found.The use of the microscope was found to significantly increase the odds of longer operative time, but not influence rates of postoperative complications. Thus, without evidence from this study that the microscope decreases complications, the use of the microscope should be at the surgeon's discretion, validating the use of both macro and micro approaches to discectomy as acceptable standards of care.

Objective A large national surgical registry was used to establish national benchmarks and associated predictors of major neurologic complications (i.e., coma and stroke) after surgical clipping of unruptured intracranial aneurysms. Methods The American College of Surgeons National Surgical Quality Improvement Program data set between 2007 and 2013 was used for this retrospective cohort analysis. Demographic, comorbidity, and operative characteristics associated with the development of a major neurologic complication (i.e., coma or stroke) were elucidated using a backward selection stepwise logistic regression analysis. This model was subsequently used to fit a predictive score for major neurologic complications. Results Inclusion criteria were met by 662 patients. Of these patients, 57 (8.61%) developed a major neurologic complication (i.e., coma or stroke) within the 30-day postoperative period. On multivariable analysis, operative time (log odds 0.004 per minute; 95% confidence interval [CI], 0.002–0.007), age (log odds 0.05 per year; 95% CI, 0.02–0.08), history of chronic obstructive pulmonary disease (log odds 1.26; 95% CI, 0.43–2.08), and diabetes (log odds 1.15; 95% CI, 0.38–1.91) were associated with an increased odds of major neurologic complications. When patients were categorized according to quartile of a predictive score generated from the multivariable analysis, rates of major neurologic complications were 1.8%, 4.3%, 6.7%, and 21.2%. Conclusions Using a large, national multi-institutional cohort, this study established representative national benchmarks and a predictive scoring system for major neurologic complications following operative management of unruptured intracranial aneurysms. The model may assist with risk stratification and tailoring of decision making in surgical candidates.

Previous studies have demonstrated that increasing age is associated with decreased rates of operative management and gross total resection in patients with vestibular schwannomas.The American College of Surgeons National Surgical Quality Improvement Program data registry was used for this retrospective cohort analysis. Patients enrolled in the registry from 2007 to 2013 with a diagnosis of a benign neoplasm of a cranial nerve were included. The association between age and postoperative morbidity and mortality was evaluated by the use of multivariable logistic regression analyses.Of 565 patients included for analysis, the mean (median) age was 51 (53) years. Three clusters were evaluated:50, 50-69, and ≥70 years. Mortality (0% vs. 1.03% vs. 4.55%, P = 0.012), stroke (0% vs. 0.69% vs. 6.82%, P0.001), and ventilator weaning failure (0.43% vs. 2.41% vs. 6.82%, P = 0.014) increased with age. Mean age was significantly greater among patients who died (70.60 vs. 50.87 years, P = 0.002) or had a stroke (68.00 vs. 50.89 years, P = 0.006), cardiac arrest (71.50 vs. 50.89 years, P = 0.038), or coma (74.00 vs. 50.96 years, P = 0.020) and those who failed ventilator weaning (62.55 vs. 50.82, P = 0.006). Age as both a continuous (odds ratio 1.10, 95% confidence interval 1.03-1.18) and categorical variable (age 70+ years odds ratio 78.88, 95% confidence interval 3.41-1825.57) was associated with an increased odds of composite morbidity.In patients undergoing surgery for benign cranial nerve neoplasms, increasing age is associated with increased mortality, stroke, coma, and ventilator weaning failure. Composite complication rates are significantly greater in patients ≥70 years, with a near 80-fold increased risk of complications.

OBJECT Endoscopic approaches to the anterior craniocervical junction are increasing in frequency. Choice of oral versus endoscopic endonasal approach to the odontoid often depends on the relationship of the C1–2 complex to the hard palate. However, it is not known how this relevant anatomy changes with age. We hypothesize that there is a dynamic relationship of C-2 and the hard palate, which changes with age, and potentially affects the choice of surgical approach. The aim of this study was to characterize the relationship of C-2 relative to the hard palate with respect to age and sex. METHODS Emergency department billing and trauma records from 2008 to 2014 were reviewed for patients of all ages who underwent cervical or maxillofacial CT as part of a trauma evaluation for closed head injury. Patients who had a CT scan that allowed adequate visualization of the hard palate, opisthion, and upper cervical spine (C-1 and C-2) were included. Patients who had cervical or displaced facial/skull base fractures, a history of rheumatoid arthritis, or craniofacial anomalies were excluded. The distance from McGregor's palatooccipital line to the midpoint of the inferior endplate of C-2 (McL–C2) was measured on midsagittal CT scans. Patients were grouped by decile of age and by sex. A 1-way ANOVA was performed with each respective grouping. RESULTS Ultimately, 483 patients (29% female) were included. The mean age was 46 ± 24 years. The majority of patients studied were in the 2nd through 8th decades of life (85%). Significant variation was found between McL–C2 and decile of age (p < 0.001) and sex (p < 0.001). The mean McL–C2 was 27 mm in the 1st decade of life compared with the population mean of 37 mm. The mean McL–C2 was also noted to be smaller in females (mean difference 4.8 mm, p < 0.0001). Both decile of age (p = 0.0009) and sex (p < 0.0001) were independently correlated with McL–C2 on multivariate analysis. CONCLUSIONS The relationship of C-2 and the hard palate significantly varies with respect to age and sex, descending relative to the hard palate a full centimeter on average in adulthood. These findings may have relevance in determining optimal surgical approaches for addressing pathology involving the anterior craniocervical junction.

BACKGROUND Autograft harvesting for spine arthrodesis has been associated with longer operative times and increased blood loss. Allograft compared to autograft in spinal fusions has not been studied in a multicenter cohort. METHODS Patients enrolled in the ACS-NSQIP registry between 2012 and 2013 who underwent cervical or lumbar spinal fusion with either allograft or autograft through a separate incision were included for analysis. The primary outcomes of interest were operative time, length of stay, blood transfusion, and surgical site infection (SSI). RESULTS A total of 6790 and 6718 patients received a cervical or lumbar spinal fusion, respectively. On unadjusted analysis in both cervical and lumbar cohorts, autograft was associated with increased rates of blood transfusion (cervical: 2.9% vs. 1.0%, P

We present a patient with subacute diencephalic angioencephalopathy (SDAE), a poorly understood syndrome of progressive confusion, disorientation, and dementia that rapidly deteriorates to severe encephalopathy and death. This is the seventh and most thoroughly investigated report of this exceedingly rare diagnosis to date, and we present the first evidence of a potential sentinel syndrome that may allow for earlier diagnosis and therapeutic intervention. We also review the relevant literature, and highlight new evidence that suggests that SDAE and the related disorder, subacute brainstem angioencephalopathy (SBAE), represent severe and terminal variants of posterior reversible encephalopathy syndrome (PRES). Taken together, we suggest a new understanding of SDAE/SBAE and PRES as a spectrum of hypertension-associated non-inflammatory vascular encephalopathies that are mediated by a loss of venous autoregulation, marked by cytotoxic edema, and that ultimately produce subacute-to-acute diencephalic, brainstem, and posterior fossa injuries with devastating neurologic consequences.

Crossed cerebellar diaschisis is a rare finding of hemispheric cerebellar depression following contralateral cerebral injury, hypothesized to result from excessive neuronal excitatory synaptic activity along cortico-pontine-cerebellar pathways. The phenomenon is typically observed following ischemic stroke, but has also been characterized during seizure activity--in particular, status epilepticus (SE). Neurological outcome has varied widely in published reports, with some patients achieving full neurologic recovery, while others experience persistent disability.Case report and literature review.We present a 54-year-old man found unresponsive with a right hemispheric syndrome several days after discharge following amygdalohippocampectomy for refractory right temporal lobe epilepsy. Prolonged electroencephalogram demonstrated one subclinical right frontal seizure, along with right frontal periodic lateralized epileptiform discharges, presumed to be associated with SE preceding his admission. Initial MRI demonstrated restricted diffusion on diffusion weighted imaging in the right cerebral hemisphere, ipsilateral thalamus, and contralateral cerebellum. A head CT one week later showed diffuse sulcal effacement with loss of gray-white differentiation in the right frontal and insular regions with low attenuation changes of right thalamus. An MRI showed worsened diffusion restriction, despite a corresponding increase in perfusion. The patient remained paretic at discharge and follow-up. Follow-up MRI at 2 months demonstrated pronounced right cerebral and left cerebellar atrophy, loss of gray matter in much of the right cerebrum, and scattered areas of T2 hyperintensity, consistent with permanent right fronto-temporal neuronal loss.Collectively, these observations indicate that imaging findings of persistent cerebral restricted diffusion and cytotoxic edema in the subacute post-ictal period may predict irreversible neuronal injury and poor long-term outcome-even when accompanied by evidence of cortical hyperperfusion and recovery of second- and third-order neurons along the involved circuit.

OBJECTIVEThe mechanism by which greater institutional case volume translates into improved outcomes after surgical clipping of unruptured intracranial aneurysms (UIAs) is not well established. The authors thus aimed to assess the effect of case volume on the rate of various types of complications after clipping of UIAs.METHODSUsing information on the outcomes of inpatient admissions for surgical clipping of UIAs collected within a national database, the relationship of institutional case volume to the incidence of different types of complications after clipping was investigated. Complications were subdivided into different categories, which included all complications, ischemic stroke, intracerebral hemorrhage, medical complications, infectious complications, complications related to anesthesia, and wound complications. The relationship of case volume to different types of complications was assessed using linear regression analysis. The relationships between case volume and overall complication and stroke rates were fit with both linear and quadratic equations. The numerical cutoff for institutional case volume above and below which the authors found the greatest differences in mean overall complication and stroke rate was determined using classification and regression tree (CART) analysis.RESULTSBetween October 2012 and September 2015, 125 health care institutions reported patient outcomes from a total of 6040 cases of clipping of UIAs. On linear regression analysis, increasing case volume was negatively correlated to both overall complications (r2 = 0.046, p = 0.0234) and stroke (r2 = 0.029, p = 0.0557) rate, although the relationship of case volume to the complication (r2 = 0.092) and stroke (r2 = 0.067) rate was better fit with a quadratic equation. On CART analysis, the cutoff for the case number that yielded the greatest difference in overall complications and stroke rate between higher- or lower-volume centers was 6 cases/year and 3 cases/year, respectively.CONCLUSIONSAlthough the authors confirm that increasing case volume is associated with reduced complications after clipping of UIAs, their results suggest that the relationship between case volume and complications is not necessarily linear. Moreover, these results indicate that the effect of case volume on outcome is most evident between very-low-volume centers relative to centers with a medium-to-high volume.

This study moves beyond previous cohort studies and benchmark data by studying a population of elective spine surgery from a multicenter registry in an effort to validate, disprove, and/or identify novel risk factors for dural tears.A retrospective cohort analysis queried a multicenter registry for patients with degenerative spinal diagnoses undergoing elective spinal surgery from 2010-2014. Multivariable logistic regression analysis interrogated for independent risk factors of dural tears.Of 104,930 patients, a dural tear requiring repair occurred in 0.6% of cases. On adjusted analysis, the following factors were independently associated with increased likelihood of a dural tear: ankylosing spondylitis vs. intervertebral disc disorders, greater than two levels, combined surgical approach and posterior approach vs. anterior approach, decompression only vs. fusion and decompression, age groups 85+, 75-84 and 65-74 vs.65, obesity (BMI ≥30), corticosteroid use and preoperative platelet count150,000.This multicenter study identifies novel risk factors for dural tears in the elective spine surgery population, including corticosteroids, thrombocytopenia, and ankylosing spondylitis. The results of this analysis provide further information for surgeons to use both in operative planning and in preoperative counseling when discussing the risk of dural tears.

The effect of age on risk of intracranial aneurysm rupture is not well understood. We investigated the clinical course of patients 65 years and older with conservatively managed unruptured intracranial aneurysms (UIA) and determined risk factors for rupture in this population.We reviewed prospectively collected data on baseline characteristics and long-term follow-up for patients aged 65 years and older with an UIA that were initially managed with observation. The association between patient and aneurysmal characteristics and risk of rupture was performed using a multivariate Cox proportional hazard regression model.There were 214 patients (mean age: 74.7 years, SD: 6.0) included in our study. The median follow-up time was 3.7 years, with a cumulative follow-up time of 883.7 person-years. During the study period, seven patients (3.3%) received interventional treatment of their UIA and eight patients (3.7%) experienced aneurysmal subarachnoid hemorrhage, yielding an annual risk of rupture of 0.9%. All aneurysms that ruptured were at least 10 mm in size. Increasing patient age [unit relative risk (RR) 1.19, 95% CI: 1.07-1.36, P=0.002], larger aneurysmal size (unit RR 1.10, 95% CI: 1.02-1.17, P=0.021), and increasing PHASES Score (unit RR 1.62, 95% CI: 1.32-2.06, P0.001) were associated with higher risk of rupture.Our data do not suggest that UIA in older patients carry a high risk of rupture. A conservative approach appears justified in these patients, with the exception of selected patients with larger aneurysms (10 mm in diameter) and low risk of interventional procedure.

The purpose of this study was to systematically compare the effectiveness and safety of full-endoscopic discectomy (FED) and micro-endoscopic discectomy (MED) with open discectomy (OD) for the treatment of symptomatic lumbar disc herniation.Electronic searches were performed using six databases from their inception to February 2016, identifying all relevant randomized controlled trials and comparative observational studies comparing either FED or MED with OD. Data were extracted and analyzed according to predefined clinical endpoints.Twenty three studies were selected for analysis, including 421 FED, 6914 MED, and 21,152 OD cases. No significant difference was found between FED and OD in regards to postoperative visual analog scale (VAS) leg pain scores (WMD 0.03, P=0.93). Similar results were obtained for MED vs OD (WMD 0.09, P=0.18). In terms of postoperative Oswestry disability index (ODI), both FED and MED were similar to OD (WMD -2.60, P=0.32 and WMD -1.00, P=0.21, respectively). FED had a significantly shorter operative duration compared to OD (54.6 vs 102.6min, P=0.0001). MED alone and endoscopic approaches overall (including MED and FED) demonstrated significantly lower estimated blood loss (44.3 vs 194.4mL, P=0.03 and 38.2 vs 203.5mL, respectively, both p0.05). FED alone demonstrated a trend towards lower estimated blood loss in comparison to OD (3.3 vs 244.9mL, P=0.07). No difference was found in overall complications, recurrence or reoperation rates, dural tears, root injury, wound infections, and spondylodiscitis between FED vs OD, or MED vs OD.Based on this meta-analysis, FED and MED appear to be safe and efficacious alternatives to traditional approaches, but these results require further investigation and validation by prospective randomized studies.

OBJECTIVE Hypoplasia of the A

STUDY DESIGN A retrospective review of a consecutive series of spinal fusions comparing patient and procedural characteristics of patients who developed surgical site infections (SSIs) after spinal fusion. OBJECTIVE It is known that increased surgical time (incision to closure) is associated with a higher rate of postoperative SSIs. We sought to determine whether increased total anesthetic time (intubation to extubation) is a factor in the development of SSIs as well. SUMMARY AND BACKGROUND DATA In spine surgery for deformity and degenerative disease, SSI has been associated with operative time, revealing a nearly 10-fold increase in SSI rates in prolonged surgery. Surgical time is associated with infections in other surgical disciplines as well. No studies have reported whether total anesthetic time (intubation to extubation) has an association with SSIs. METHODS Surgical records were searched in a retrospective fashion to identify all spine fusion procedures performed between January 2010 and July 2012. All SSIs during that timeframe were recorded and compared with the list of cases performed between 2010 and 2012 in a case-control design. RESULTS There were 20 (1.7%) SSIs in this fusion cohort. On univariate analyses of operative factors, there was a significant association between total anesthetic time (Infection 7.6 ± 0.5 hrs vs. no infection -6.0 ± 0.1 hrs, P

The aim of our study was to determine independent predictors of discharge disposition to rehabilitation or skilled care (SC) facilities and investigate whether discharge location is associated with unplanned readmission and/or reoperation rates. All elective spinal surgery patients in a national surgical registry were analyzed using between 2011 and 2012. Multivariable logistic regression analysis was used to assess for predictors of discharge to rehabilitation or SC facilities versus home as well as to determine whether discharge disposition was significantly associated with the 30-day unplanned readmission or reoperation. Of 34,023 elective spinal surgery patients, the distribution of discharge locations was as follows: 30,606 (90.0%) discharged home, 1674 (4.9%) discharged to rehabilitation, and 1743 (5.1%) discharged to SC. Patients discharged home were associated with the lowest complication rate relative to rehabilitation and SC facilities. Following multivariable regression analysis, there was a significant increase in the odds of discharge to rehabilitation associated with age, male gender, current smoking, ASA class three and four, history of diabetes, operative time, total hospital length of stay, preoperative neurologic morbidity and having at least one postoperative morbidity event. Moreover, there were 804 (4.06%) 30-day unplanned readmissions and 822 (2.45%) unplanned reoperations. After risk adjustment, discharge to rehabilitation was independently associated with decreased odds of 30-day unplanned readmission (OR=0.41; p=0.008) but not reoperation.

Objectives To quantify the number of shunt-related imaging studies that patients with ventricular shunts undergo and to calculate the proportion of computed tomography (CT) scans associated with a surgical intervention. Study design Retrospective longitudinal cohort analysis of patients up to age 22 years with a shunt placed January 2002 through December 2003 at a pediatric hospital. Primary outcome was the number of head CT scans, shunt series radiograph, skull radiographs, nuclear medicine, and brain magnetic resonance imaging studies for 10 years following shunt placement. Secondary outcome was surgical interventions performed within 7 days of a head CT. Descriptive statistics were used for analysis. Results Patients (n = 130) followed over 10 years comprised the study cohort. The most common reasons for shunt placement were congenital hydrocephalus (30%), obstructive hydrocephalus (19%), and atraumatic hemorrhage (18%), and 97% of shunts were ventriculoperitoneal. Patients underwent a median of 8.5 head CTs, 3.0 shunt series radiographs, 1.0 skull radiographs, 0 nuclear medicine studies, and 1.0 brain magnetic resonance imaging scans over the 10 years following shunt placement. The frequency of head CT scans was greatest in the first year after shunt placement (median 2.0 CTs). Of 1411 head CTs in the cohort, 237 resulted in surgical intervention within 7 days (17%, 95% CI 15%-19%). Conclusions Children with ventricular shunts have been exposed to large numbers of imaging studies that deliver radiation and most do not result in a surgical procedure. This suggests a need to improve the process of evaluating for ventricular shunt malfunction and minimize radiation exposure.

Objective Obesity has been associated with increased risk for postoperative CSF leak in patients with benign cranial nerve tumors. Other measures of postoperative morbidity associated with obesity have not been well characterized. Methods Patients enrolled in the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) from 2007 to 2013 with a diagnosis code of a benign neoplasm of a cranial nerve were included. The primary outcome of postoperative morbidity was analyzed as well as secondary outcomes of readmission and reoperation. The main covariate of interest was body mass index (BMI). Results A total of 561 patients underwent surgery for a benign cranial nerve neoplasm between 2007 and 2013. Readmission data, available for 2012–2013(n = 353), revealed hydrocephalus, facial nerve injury, or CSF leak requiring readmission or reoperation occurred in 0.85%, 1.42%, and 3.12%, respectively. Composite morbidity included wound complications, infection, respiratory insufficiency, transfusion requirement, stroke, venous thromboembolism, coma and cardiac arrest. On multivariable analysis patients with class I (BMI 30–34.9) and II (BMI 35–39.9) obesity showed trends towards increasing return to operating room, though not significant, but there was no trend for composite complications in class I and II obesity patients. However, class III obesity, BMI ≥ 40, was associated with increased odds of composite morbidity (OR 4.40, 95% CI 1.24-15.88) and return to the operating room (OR 5.97, 95% CI 1.20–29.6) relative to patients with a normal BMI, 18.5–25. Conclusions Obesity is an independent and important risk factor for composite morbidity in resection of benign cranial nerve neoplasms, and as such, merits discussion during preoperative counseling.

Patients recovering from decompressive laminectomy without fusion may require assistance with activities of daily living and physical/occupational therapy upon hospital discharge.To examine comorbidities and perioperative characteristics of patients undergoing lumbar decompression for associations with discharge status using a multicenter database.A multicenter database was used for this retrospective cohort analysis. Patients admitted from home with degenerative spine disease for lumbar decompression without fusion were included. Thirty-day outcomes and operative characteristics were compared as a function of patient discharge using chi-square and Wilcoxon Rank Sum tests. Multivariable logistic regression was used to determine factors associated with discharge to a nonhome facility.Of the 8627 patients included for analysis, 9.7% were discharged to a nonhome facility. On multivariable analysis, age (85+ vs65, odds ratio [OR] 13.59), number of levels of decompression (3+ vs 1, OR 1.75), African American race vs Non-Hispanic or Hispanic White (OR 1.87), female vs male gender (OR 1.97), body mass index (BMI) (40+ vs 18.5-24.9, OR 1.74), American Society of Anesthesiologists physical classification status (4 vs 1 or 2, OR 2.35), hypertension (OR 1.29), dependent functional status (OR 3.92), diabetes (OR 1.47), smoking (OR 1.40), hematocrit (35 vs 35+, OR 1.76), international normalized ratio (≥1.3 vs1.3, OR 2.32), and operative time (3+ h vs1 h, OR 5.34) were significantly associated with an increased odds of discharge to nonhome facilities.Preoperative status and operative course variables can influence discharge disposition in lumbar decompression patients. Identifying specific factors that contribute to a greater likelihood of dismissal to skilled facility or rehabilitation unit can further inform both surgeons and patients during preoperative counseling and disposition planning.

Background: Dural arteriovenous fistulae (dAVF) are common intracranial vascular lesions typically becoming symptomatic with cortical venous hypertension and possible hemorrhage. Here, we present a case illustration of a petrous apex dAVF with marked medullary venous hypertension and a unique clinical presentation. Methods: Case report. Results: A 72-year-old female, whose clinical progression was significant for altered mental status and progressive weakness, presented with diplopia, right leg paresis, and ataxia. Magnetic resonance imaging revealed edema involving the medulla. On digital subtraction cerebral angiogram, the patient was found to have a petrous apex dAVF, Cognard type IV. Following treatment with Onyx embolization, her symptoms rapidly improved, with complete resolution of diplopia and drastic improvement of her ataxia. Conclusion: The importance of this case is in the presentation and deterioration of the clinical exam, resembling an acute ischemic event. Further, this case illustrates that dAVF may cause venous hypertension with rapid onset of focal neurologic symptoms not exclusive to cortical locations.

Background Shunt infections are a major complication following ventricular shunts in adults that lead to increased heath care costs, patient morbidity, and mortality. Methods to decrease shunt infection include antibiotic-impregnated catheters, protocol-based surgery, and shunt reservoir antibiotic injection. Methods An Institutional Review Board–approved retrospective review was performed for all adult shunt surgeries performed from January 2000 to September 2013 at a single academic institution. Records were cross-indexed with hospital billing records to identify patients who received antibiotic injections and cross-referenced with a prospective infection control database of all surgical site infections. The primary outcome measure was shunt infection within 1 year of surgery. Results Five-hundred thirteen adult patients met inclusion criteria. Antibiotic reservoir injection was associated with a significantly lower rate of infection (2.6%) when compared with no injection (6.3%, P = 0.0455). The antibiotic injection group also included significantly more patients with infection risk factors than the control group (38.8% vs. 18.0%, P Conclusion Antibiotic reservoir injection is an effective method of reducing shunt infections in adults when combined with standard infection control measures.

To determine the rate of surgical site infection (SSI) after resection of an intracranial neoplasm using the American College of Surgeons National Surgical Quality Improvement Program data set and to identify potential risk factors associated with SSI.The National Surgical Quality Improvement Program Participant Use Data File was queried during the period 2006-2013 for patients who underwent a resection for an intracranial neoplasm. Multivariable logistic regression analysis was used to identify risk factors associated with SSI.Inclusion criteria were met by 12,021 patients. SSI occurred at a rate of 2.04%. SSI was significantly associated with increased rates of return to the operating room (56.1% vs. 4.0%, P0.001) and postoperative lengths of stay30 days (5.3% vs. 1.3%, P0.001) on unadjusted bivariate analysis. On multivariable analysis, age (odds ratio [OR] = 0.991, 95% confidence interval [CI] = 0.982-0.999) and female sex (OR = 0.697, 95% CI = 0.538-0.902) were associated with a reduction in the odds of SSI. Preoperative wound infections (OR = 3.833, 95% CI = 1.834-8.0011) and operative times4 hours (OR = 1.891, 95% CI = 1.298-2.756) were associated with an increased odds of SSI. Among cases with available chemotherapy data (n = 3504), recent chemotherapy (OR = 3.007, 95% CI = 1.460-6.196) was associated with an increased odds of SSI.This study identified patient risk factors that may assist clinical decision making regarding patient risk stratification, timing of surgery, and preoperative antibiotic prophylaxis for patients with an intracranial neoplasm undergoing craniotomy.

Orientational metaphors that associate good with up and bad with down illustrate that spatial terms can be used to describe positivity and negativity. The present work examined how the association between valence and verticality influences memory for the locations of emotionally evocative stimuli. In two spatial memory experiments, participants viewed positive and negative images from the International Affective Picture System in various locations and then reproduced each image's location from memory. Results indicated that memories of location are influenced by stimulus valence, such that positive items are biased upward relative to negative items. A third experiment extended these results to yearbook photos that had been paired with positive or negative behavioural descriptions. The findings suggest that affective responses evoke spatial representations, leading to systematic biases in spatial memory.

Brain tumors such as diffuse infiltrating gliomas continue to represent a major clinical challenge. Overall survival for patients diagnosed with glioblastoma, the most common primary brain tumor, remains less than 2 years despite intensive multimodal therapy with surgery, radiation, and chemotherapy. However, advances have been made in standard therapies and novel treatments that are showing great potential. These advances reflect careful study performed in the context of clinical trials. Neurosurgeons have played and will continue to play key parts in these studies. In this manuscript, we review clinical trials in neuro-oncology from a neurosurgical point of view and discuss potential roles for neurosurgeons in advancing glioma therapy in the future.

INTRODUCTION:Recent studies suggest that diabetic patients may be more likely to exhibit back pain. Correlating diabetic disease progression to the presence of back pain could provide insight into the relationship between these conditions.METHODS:A total of 67 132 patients within our institutional d

Quality of life (QoL) in people with schizophrenia and other serious mental illnesses (SMI) is an important outcome goal, yet there is no consistent definition of the construct. We examined three aspects of QoL in persons with SMI: overall life satisfaction, physical health-related QoL (HRQoL), and mental HRQoL. This study had two primary aims: first, to examine whether there are differences in physical and mental HRQoL in persons with SMI, and, second, to investigate the cognitive, clinical, and functional correlates of the three QoL indicators. Participants were 48 persons with SMI who completed assessments of QoL, cognition, functional capacity, psychiatric symptomatology, and medical comorbidity. Results indicate that participants experience similar levels of physical and mental HRQoL, and these two constructs are not related to one another. Physical HRQoL is associated with less medical comorbidity, while mental HRQoL is associated with negative and depressive symptoms. Overall life satisfaction was associated with fewer psychiatric symptoms and less medical comorbidity. This study adds to the important literature defining distinct domains of QoL and supports the necessity of addressing both physical and mental health factors as they relate to recovery and well-being among persons with SMI.

Objective. To create, implement, and evaluate a pharmacy course on motivational interviewing. Design. A 3-hour elective course was created to train doctor of pharmacy (PharmD) students in brief patient-centered motivational interviewing counseling strategies that have proven effective with the types of health issues most commonly addressed in pharmacy settings. Students were assisted in developing their skills through required readings, interactive lectures, in-class demonstrations and practice sessions, out of class skills practice, one-on-one supervision provided by doctoral level clinical health psychology students, and written reflections on each class session. Assessment. Students demonstrated significant improvement in motivational interviewing skills and a high level of motivation for and confidence in using these skills in their future practice. Students overall assessment of the course and supervision process was highly positive. Conclusion. This patient-centered counseling skills course was feas...

Cortical bone trajectory, also called cortical screw trajectory, is a novel, less invasive fusion alternative for disorders affecting the lumbar spine. Cortical screw constructs have several touted advantages over traditional pedicle screw constructs. First, the surgical exposure required for instrumentation placement is less than that required for traditional pedicle screw placement. This reduced exposure can help reduce blood loss and other approach-related morbidity. Second, the unique screw trajectory, along with a cortically threaded screw, allows for increased cortical bone purchase within the lamina and pedicle. This improved bone purchase can result in improved screw pullout strength, and possibly reduce the chance of screw loosening. Finally, cortically placed screw heads rest on top of the vertebral lamina, which is significantly more medial than traditional pedicle screws, making them more accessible and rod placement more straightforward. Cortical bone trajectory has been validated with several biomechanical cadaveric studies and shows promise with early clinical testing. The cortical screw trajectory may provide patients with lumbar spine pathology a less invasive fusion alternative. This article serves to describe the operative technique and provides a current review of the literature.