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Background: We have developed P10s-PADRE, a carbohydrate-mimetic-based peptide, cancer vaccine and demonstrated its safety and immunogenicity in a Phase I clinical trial performed in stage IV breast cancer patients. HR+/HER2- breast cancer is the most common form of breast cancer diagnosed in the United States. These patients face a persistent risk of distant recurrence long after completion of their treatment and new strategies to activate anti-tumor immune responses can improve outcomes of standard therapies. The current study was performed to examine the feasibility, safety and immunogenicity of adding P10s-PADRE to standard-of-care chemotherapy in HR+/HER2− early-stage breast cancer patients. Methods: Five combination schedules were designed based on the timing of immunizations relative to a standard-of-care neoadjuvant chemotherapy regimen. Induction of on-treatment antibody and cellular responses, including T-cells, natural killer (NK) cells, and cytokines was determined. Tumor-infiltrating lymphocytes were quantified in core and surgical biopsies. The data were used to define the treatment effect in general and the vaccine contribution in particular. Results: Combination of P10s-PADRE with chemotherapy was safe and immunogenic. Antibody response was superior in a particular combination schedule, called schedule C, where 3 weekly immunizations preceded the first dose of chemotherapy. We observed that the schedule C, relative to other schedules, displayed an increase in CD16 expression on NK cells, a drop in serum IFN-γ, and an increase in quantity of stromal TILs in residual tumors. Subjects demonstrated a significant reduction in the size of their primary tumor and three subjects achieved pCR. Conclusions: The timing of the immunization relative to the chemotherapy seems to define the type and strength of the immune responses elicited. A particular combination schedule, schedule C, appears promising and the results warrant the conduct of randomized phase II trials. Citation Format: Issam Makhoul, Saddam M Ibrahim, Muhammad Abu-Rmaileh, Fariba Jousheghany, Eric Siegel, Lora J Rogers, John J Lee, Sergio Pina-Oviedo, Ginell R Post, Thaddeus Beck, Thomas Kieber-Emmons, Behjatolah Monzavi-Karbassi. Timing of the immunization defines immune signature of a peptide cancer vaccine combined with Neoadjuvant chemotherapy in HR+ breast cancer patients [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-14-15.

Breast cancer patients diagnosed with HR+/HER2– tumors face a persistent risk of distant recurrence long after completion of their treatment. Strategies to induce anti-tumor immune responses could complement standard-of-care therapies for these patients. The current study was performed to examine the feasibility, safety and immunogenicity of adding P10s-PADRE to standard-of-care chemotherapy in HR+/HER2− early-stage breast cancer patients. Twenty-five subjects were treated in a single-arm Phase Ib clinical trial. Five different immunization schedules were considered to evaluate the feasibility of eliciting an immune response. The primary immunogenicity endpoint was antibody titer. The expression of several activation markers on natural killer (NK) cells and serum concentrations of Th1/Th2 cytokines were also examined. The percentage of tumor-infiltrating lymphocytes (TILs) was determined. Antibody response was superior in schedule C where 3 weekly immunizations preceded the first dose of chemotherapy. A significant change in CD16, NKp46 and CD94 expression levels on NK cells and a rise in serum content of IFN-γ was observed after treatment. Schedule C showed an increase in TILs in residual lesions. The combination therapy is safe and immunogenic with treatment schedule C being immunologically promising. Randomized trials focused on long-term survival outcomes are needed to evaluate clinical benefits.

BACKGROUND Live streaming surgery is a developing communication platform in medicine. To maximize the technological advances that allow for the live streaming of surgery, it is crucial to have an understanding of the various video-capturing devices that are available and their pros and cons of implementation. Possible barriers to the widespread use of live streaming surgery include cost, concerns about patient safety and privacy, and limited understanding of the current available resources. In this article, we present the results of our literature review of techniques for live streaming of surgery as a means to inform readers and promote their implementation. METHODS We conducted a literature review of the literature to identify previous articles indexed in PubMed and Ovid. We used the following search terms: [Surgery AND Streaming], which generated 32 articles for initial review. References were reviewed within each document to find similar articles that were not captured by the initial search. The article selection criteria were peer-reviewed publications, case reports, and case series describing the use of live surgical streaming technologies. RESULTS Literature review showed enhanced surgeon interaction with viewers and improved anatomy scores with the widespread use of live streaming. Surgeons reported positive feedback and wished to engage in more sessions in the future. The largest barriers to implementation of streaming technology are video quality through the Internet and patient information protection. CONCLUSIONS Live streaming of surgery for educational purposes has not been widely accepted in surgical training programs to date. Streaming accessibility has advanced over the past 2 decades with the availability of handheld mobile devices. However, little has been done to allow for live streaming of surgery to trainees in a manner compliant with the Health Portability Insurance and Accountability Act.

The Society of Neurological Surgeons (SNS), founded in 1920, is one of the oldest neurosurgical society in the world. The founding members were prominent surgeons that met with the idea of furthering the field of neurosurgery. Initial meetings were forums to observe and discuss new surgeries. During the first 6 meetings of the SNS, surgical cases from the areas of cranial trauma, epilepsy, spinal cord tumors, brain tumors, pituitary tumor, trigeminal neuralgia, and cerebellar tumors were discussed. Publications from the members during that time included articles on the use of intracranial hypertonic saline, trigeminal neuralgia, brachial plexus injuries, management of head injury, spinal cord tumors, cervical spine trauma, and intracranial hemorrhage in the newborn. The members also invited lecturers from other specialties, such as neurology, ophthalmology, radiology, and pathology, typifying the interdisciplinary nature of neurosurgical practice. The meetings served as a forum to build consensus on neurosurgical treatment methods. Cases that ultimately changed the practice of neurosurgery at that time will be profiled. The SNS began as a traveling club of neurosurgical leaders who learned from each other's clinical experience to mold this burgeoning new field. However, the members made an impact on how neurosurgery was practiced nationally.

Introduction Fetal intracranial hemorrhage (ICH) is a rare but serious prenatal diagnosis. Predisposing factors include maternal trauma and fetal coagulation dysfunction. Maternal vitamin K deficiency has been described as an etiology. We present a case of maternal vitamin K deficiency associated with fetal ICH after percutaneous biliary drain (PBD) placement in a complicated cholecystectomy with injury to the common bile duct. Case presentation A 21-year-old woman, G2P1, presented at 23 weeks and 3 days of gestation with epigastric pain, nausea and vomiting. Right upper quadrant ultrasound diagnosed cholelithiasis. The patient was managed conservatively and discharged. She returned four days later, at 24 weeks of gestation, with worsening symptoms and ultrasound showing acute cholecystitis. She underwent laparoscopic cholecystectomy. Increasing bilirubin and imaging showed a transected biliary duct that required percutaneous biliary drain (PBD) placement. The patient was discharged and followed up at a high-risk obstetric clinic. Prenatal ultrasound showed bilateral ventriculomegaly with features of ICH. Maternal vitamin K deficiency was confirmed with PIVKA-II testing. The patient received vitamin K supplementation with normalization of the coagulopathy. Delivery occurred at 36 weeks of gestation via cesarean delivery after preterm premature rupture of membranes for fetal macrocrania. The neonate was discharged to a hospice. Discussion Maternal and neonatal etiologies for ICH include malabsorption and coagulopathy. Maternal vitamin K deficiency should be considered when coagulopathy is present. This case highlights that maternal vitamin K deficiency due to biliary diversion and malabsorption increases the risk of fetal ICH, which impacts pregnancy and neonatal outcomes., Highlights • Maternal vitamin K deficiency due to biliary diversion and malabsorption may predisp fetal intracranial hemorrhage. • Fetal intracranial hemorrhage may impact pregnancy and neonatal outcomes, particularly if severe. • Monitoring maternal coagulation may aid in the diagnosis of maternal vitamin K deficiency.

Objective The prevalence of physicians experiencing work-related musculoskeletal disorders is high. Traditionally, minimally invasive surgery (MIS) sacroiliac joint (SIJ) fusions are performed with the patient oriented in the prone position, with an incision made inferior to the iliac crest. However, a novel technique that orients the patient in the lateral decubitus position has the potential of significantly enhancing ergonomics and ease of approach. The primary objectives of this study were to quantify surgical parameters, describe this 'lateral-decubitus MIS' technique, and identify imaging angle parameters that predict feasibility. Methods A prospective cohort of patients who underwent MIS SIJ arthrodesis in the lateral decubitus position was evaluated at a single institution between 2017 and 2020. Medians and ranges of intraoperative blood loss, operative time, revision rate, infection, and total radiation dose were recorded. Sacral inlet and outlet angles were defined and collected to assess for operative candidacy. Results Thirty-nine cases were identified in 34 patients who underwent the technique with an age range of 31–78 years. Median blood loss was 22.5 mL, operating room time was 32.5 minutes, and radiation dose was 30.9 rads. Average sacral inlet was 24.51° and average sacral outlet was 65.44°. Median length of stay was 0.94 days. No cases were aborted or required revision. A total of 93% of study participants reported improvement in pain. Operative parameters were comparable to the traditional prone approach. Conclusions The aim was to provide an insight into outcomes and metrics observed from pioneering this style of procedure. A future study comparing traditional perioperative parameters together with surgical ergonomics is needed.

Summary:. Traditional livestreaming of surgery to an audience requires stationary video broadcasting infrastructure, with viewers congregating in front of a screen, while audiovisual technicians provide support in the background. In recent years, livestreaming technologies from cameras to teleconference platforms have advanced dramatically, even to allow for compliance with the Health Insurance Portability and Accountability Act of 1996 with web-based encryption. The objective of this article is to show that livestreaming surgery in medical education is possible using portable devices, with the resident and medical students as audience at home interacting on their computer or smart devices. The surgeon utilizes a head-mounted camera transmitting video feed using a wireless transmitter broadcasting to a laptop computer, which is hosting a Health Insurance Portability and Accountability Act–compliant version of Zoom. The entire setup is portable, and the surgeon is tethered neither to a cord nor to the institution’s audiovisual enterprise. This prototype setup allows the surgeon to broadcast live surgery interactively at any time and from any operating room with remote medical students and surgical residents. We posit that our medical education industry would need to condense the devices into a turnkey livestreaming camera system with optimized frames per second reception.

Bilateral ureteropelvic junction (UPJ) tears are rare. Trauma can obscure this diagnosis. The objective of this case report is to highlight the rapid diagnosis of this injury and care in the case of pregnancy. A 22-year-old pregnant female was ejected from her car and presented with abdominal pain. The patient got a computed tomography (CT)-chest, abdomen, pelvis (CT-CAP) revealing bilateral ureteral injury, which was confirmed on retrograde cystoscopy. Her injuries were treated with nephrostomy tubes with plans for definitive repair after pregnancy. Fetus remained stable throughout her care and the patient was discharged with no complications. Due to the rapid diagnosis and effective stabilization, the patient and fetus recovered well from the injuries and multiple procedures. While there are many explanations for bilateral UPJ tears, deceleration and hyperextension seem to be the two major mechanisms of this injury.

Background. While pituitary tumors are well understood, little research has been done on metastasis from primary tumors into pituitary adenomas, also known as composite tumors. Because only 34 cases of composite tumors have been reported to date, we hope to better characterize these tumors by reviewing cases reported in the literature and reviewed our own documented case, which includes next-generation sequencing. Case Presentation. A 74-year-old man presented to the emergency department with left vision loss for 3 months. He had a history of colon cancer treated with colectomy and clear cell renal carcinoma treated with left nephrectomy. A preoperative MRI demonstrated growth of a peripherally enhancing, centrally necrotic mass with sellar expansion measuring 5.7×3.1×3.0 cm. Given these findings, an endoscopic endonasal transsphenoidal resection was performed. Histological assessment revealed a composite tumor: one neoplasm was a nonfunctioning pituitary adenoma, and another neoplasm was a clear cell carcinoma. Next-generation sequencing demonstrated that the tumors shared mutations in VHL and Notch2. The patient died 2 months later from systemic metastatic cancer. Conclusion. From our literature review, most metastatic lesions in these composite tumors originated from neoplasms of the lung and kidney. Approximately 63% patients presented with ophthalmoplegia as the initial symptom while 23% displayed hormonal abnormalities. Postoperative mortality had a median of 3.5 months. In our patient, the presence of VHL and Notch2 mutations in both tumors highlights the possibility of using next-generation sequencing to help identify therapeutic targets even in complex composite neoplasms.