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In this publication, methods are presented to improve predictions of perioral soft-tissue changes following the expansion of the dental arches during orthodontic therapy. Acrylic veneers with different thicknesses were reversibly attached to the buccal surfaces of the upper and lower incisors to simulate their protrusion. The resulting morphological changes of the perioral soft-tissue surface were determined by 3D face scans. Experimentally-determined 3D soft-tissue changes are compared to numerical predictions using detailed finite-element (FE) models of the face of two individuals differing in the body mass index (BMI). The results suggest that common estimates of material constants used by the detailed and individualized FE models might be sufficient to explain absolute soft-tissue displacements although differences occurred between experimental and modeling results regarding the directions of displacements. The aim of this investigation is to create predictions of post-treatment appearance that are helpful for therapy planning.

In the current energy context, intermittent and non-dispatchable renewable energy sources, such as wind and solar photovoltaic (generation does not necessarily correspond to demand), require flexible solutions to store energy. Energy storage systems (ESS) are able to balance the intermittent and volatile generation outputs of variable renewable energies (VRE). ESS provide ancillary services such as: frequency, primary and voltage control to the power grid. In order to fulfil the power system control, ESS can switch within seconds for different operation modes. Many times, ESS imply environment impacts on landscape and society. To solve this problem, disused underground spaces, such as closed mines, can be used as underground reservoir for energy storage plants. In this paper, a comparative analysis between underground pumped storage hydropower (UPSH), compressed air energy storage (CAES) and suspended weight gravity energy storage (SWGES) with suspended weights in abandoned mine shafts is carried out. Pumped storage hydropower (PSH) is the most mature concept and account for 99% of bulk storage capacity worldwide. The results obtained show that in UPSH and CAES plants, the amount of stored energy depends mainly on the underground reservoir capacity, while in SWGES plants depends on the depth of the mine shafts and the mass. The energy stored in a SWGES plant (3.81 MWh cycle-1 with 600 m of usable depth assuming 3,000 tonne suspended weight) is much lower than UPSH and CAES plants.

The objective of this study was to evaluate the effect of energy and protein in the diet on the recovery of milk ethanol stability (MES) induced by feed restriction. Twelve Holstein and Holstein × Jersey crossbred cows with an average of 146 ± 50 DIM, 575.4 ± 70 kg of BW, and 18.93 ± 5.46 kg/d of milk yield were distributed in a 3 × 3 Latin square design with 3 treatments and 3 experimental periods. Each experimental period lasted 24 d, comprising 3 phases: a 13-d adaptation phase (100E+100P), a 4-d induction phase for milk ethanol instability (50E+50P), and a 7-d recovery phase for MES (3 treatments). The 3 treatments during the recovery phase consisted of 3 diets aiming to meet the requirements of energy and protein (100E+100P), only energy (100E+50P), or only protein (50E+100P). The diet during the adaptation and induction phases was common for all cows. The energy and protein levels to meet each cow's requirements were based on the group average. Restriction of energy and protein reduced DM, CP, and total digestive nutrient intake for cows fed 100E+50P and 50E+100P. The lowest BW was observed for cows fed 50E+100P, with no difference for BCS. During the induction phase, MES was reduced by 9 percentage units. Cows fed 100E+100P recovered MES in the first days of the recovery phase, whereas 100E+50P slightly improved MES, and 50E+100P had a constant decrease in MES. Cows fed 100E+50P and 50E+100P produced, respectively, 3.6 and 5.9 kg less milk than those fed 100E+100P. The 50E+100P treatment exhibited the highest milk fat content and SCS, along with the lowest milk lactose content. Protein content was higher in the 100E+100P treatment. Cows fed 50E+100P showed higher serum albumin levels compared with those on the 100E+100P treatment, not differing from the 100E+50P treatment. We concluded that the complete recovery of MES in cows with feed restrictions is possible only by supplying both the energy and protein requirements in the cows' diet. However, restricting energy intake poses a greater limitation on MES recovery compared with restricting protein., (The Authors. Published by Elsevier Inc. on behalf of the American Dairy Science Association®. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).)

Background: Computed tomography (CT)-guided cordotomy has been shown to be a safe and effective method for treating cancer pain in adults in a palliative care setting. Its effectiveness has been rarely reported in children. During cordotomy, patient feedback is considered essential. Unfortunately, in this report, the featured patient's age and demeanor precluded an awake cordotomy. The authors report the first case, to their knowledge, of percutaneous cordotomy with the patient under general anesthesia., Observations: An 11-year-old boy with osteosarcoma of the right pelvis presented with medically refractory unilateral nociceptive pain. The pain prevented ambulation, interfered with sleep, was the focus of his concern, and could not be relieved without sedation. A left percutaneous CT-guided cervical cordotomy while he was under general anesthesia was performed without complication and provided sufficient pain relief to allow ambulation and restorative sleep. Pain was no longer an issue for the patient and his family., Lessons: CT-guided percutaneous cervical cordotomy can be accomplished in a pediatric patient under general anesthesia. The risks of cordotomy under general anesthesia without patient feedback must be weighed against the opportunity to improve palliative care. https://thejns.org/doi/abs/10.3171/CASE2427.

Background and Objectives: One of the major challenges in training neurosurgical and orthopedic residents the technique for minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is the lack of visualization of surgical landmarks (pedicle, pars, lamina). This is due to the limited access to the bony spine through a tubular retractor, in addition to a smaller working corridor or patient-specific factors such as bony overgrowth, disk space collapse, and listhesis. These factors increase the possibility for surgical error and prolonged surgery time. With augmented reality (AR), relevant surgical anatomy can be projected directly into the user's field of view through the microscope. The purpose of this study was to assess the utility, accuracy, efficiency, and precision of AR-guided MIS-TLIF and to determine its impact in spine surgery training., Methods: At 2 centers, 12 neurosurgical residents performed a one-level MIS-TLIF on a high-fidelity lumbar spine simulation model with and without AR projection into the microscope. For the MIS-TLIF procedures with AR, surgical landmarks were highlighted in different colors on preoperative image data. These landmarks were visualized in the spinal navigation application on the navigation monitor and in the microscope to confirm the relevant anatomy. Postprocedural surveys (National Aeronautics and Space Administration Task Load Index) were given to the residents., Results: Twelve residents were included in this trial. AR-guided procedures had a consistent impact on resident anatomical orientation and workload experience. Procedures performed without AR had a significantly higher mental demand (P = .003) than with AR. Residents reported to a significantly higher rate that it was harder work for them to accomplish their level of performance without AR (P = .019)., Conclusion: AR can bring a meaningful value in MIS teaching and training to confirm relevant anatomy in situations where the surgeon will have less direct visual access. AR used in surgical simulation can also speed the learning curve., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Purpose: The purpose of this mini review is to describe metabolomics in cerebrospinal fluid (CSF) and its potential in aneurysmal subarachnoid hemorrhage (aSAH). In brain injury, patients' micro dialysis enables detecting biochemical change in brain tissue. Indicators for ischemia were detected such as lactate, pyruvate, glucose, and glutamate. In aSAH patients, the pathophysiology and the factor for poor outcome are not completely understood yet. Routine use of biomarkers in CSF, particularly in aSAH patients, is still lacking., Methods: This mini review was performed on the role of metabolomics alterations after aneurysmal subarachnoid hemorrhage., Results: We identified five clinical studies that addressed metabolomics in patients with aneurysmal subarachnoid hemorrhage., Conclusion: There is increasing evidence suggesting that biomarkers can give insight in the pathogenesis and can serve as an outcome predictor. In this mini review, we present a brief overview of metabolomics profiling in neuroscience and wish to discuss the predictive and therapeutic value in aSAH patients., (© 2023. The Author(s).)

Animals are integrated into the wider ecosystem via their foraging and behavior. The compensation hypothesis predicts that animals target their foraging efforts (i) toward nutrients that are scarce in the environment and (ii) toward nutrients that are not present in the usual diet of species, which varies across trophic levels. Understanding how foraging for resources varies locally, such as across habitat strata, and trophic levels will help to elucidate the links between the local environment and communities to the ecological functions that animals mediate. We examined whether the relative resource use of ants varies consistently along a habitat strata gradient and across trophic levels across Neotropical biomes. We placed 4500 baited tubes, each containing one of five liquid resources (sugar, amino acid, lipid, sodium, and distilled water) in one of three habitat strata (subterranean, epigaeic, and arboreal) across 60 transects in Amazon, Atlantic Forest, Caatinga, Cerrado, Pampa, and Pantanal biomes. We assessed the relative resource use of all ants across the habitat strata and among two different trophic groups across biomes. The relative preference for sugar increased from subterranean to arboreal strata in all biomes, while the relative preference for lipids decreased at this gradient in five biomes. We also found that in general sugar-consuming ants foraged more for sugar and less for lipids than predatory ants across biomes. Conversely, we found no consistency across biomes in nutrient preference of amino acid and sodium across habitat strata or trophic levels. Overall, our results indicate sugar limitation in the arboreal stratum and lipid limitation on the ground across biomes and that the trophic level of ants strongly determines their foraging efforts-possibly because ants try to fix their dietary nutrient imbalances. Hence, our findings suggest strong local niche partitioning of sugar and lipid use across habitat strata and trophic levels and that other large spatial scale processes influence the local amino acid and sodium dynamics., (© 2023 The Ecological Society of America.)

Research findings in natural sciences need to be comparable and reproducible to effectively improve our understanding of ecological and behavioural patterns. In this sense, knowledge frontiers in biodiversity studies are directly tied to taxonomic research, especially in species-rich tropical regions. Here we analysed the taxonomic information available in 470 studies on Brazilian ant diversity published in the last 50 years. We aimed to quantify the proportion of studies that provide enough data to validate taxonomic identification, explore the frequency of studies that properly acknowledge their taxonomic background, and investigate the primary resources for ant identification in Brazil. We found that most studies on Brazilian ant diversity (73.6%) explicitly stated the methods used to identify their specimens. However, the proportion of papers that provide complete data for the repository institutions and vouchered specimens is vanishingly small (5.8%). Additionally, only 40.0% of the studies consistently presented taxon authorities and years of description, rarely referencing taxonomic publications correctly. In turn, the number of specialists and institutions consulted for ant identification in Brazil has increased in the last years, along with the number of studies that explicitly provide their taxonomic procedures for ant identification. Our findings highlight a shift between generations regarding the recognition of taxonomy as fundamental science, deepening our understanding of biodiversity., (© 2023 The Authors.)

Objective: Lumbar disc herniation (LDH) is a global issue associated with potentially debilitating long-term consequences, including chronic low back pain (LBP). Short-term outcomes (<2 years) of patients with LDH have been extensively studied and demonstrate improvements in back and leg pain for both operative and conservative management. However, these improvements may not be sustained long-term (>2 years); patients with LDH may develop recurrent disc herniations, progressive degenerative disc disease, and LBP regardless of management strategy. Therefore, our objective is to determine the prevalence of chronic LBP after LDH, understand the relationship between LDH and chronic LBP, and investigate the relationship between radiological findings and postoperative pain outcomes., Methods: We performed a literature review on the PubMed database via a combination medical subject heading and keyword-based approach for long-term LBP outcomes in patients with LDH., Results: Fifteen studies (2019 patients) evaluated surgical and/or nonoperative outcomes of patients with LDH . Regardless of surgical or nonoperative management, 46.2% of patients with LDH experienced some degree of LBP long-term (range 2-27 years) as compared to a point prevalence of LBP in the general population of only 11.9%., Conclusions: Patients with LDH are more likely to experience long-term LBP compared to the general population (46.2% vs. 11.9%). Additionally, understanding the relationship between radiological findings and pain outcomes remains a major challenge as the presence of radiological changes and the degree of LBP do not always correlate. Therefore, higher quality studies are needed to better understand the relationship between radiological findings and pain outcomes., (Copyright © 2022. Published by Elsevier Inc.)

Objective: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a highly reproducible procedure for the fusion of spinal segments. We recently introduced the concept of "total navigation" to improve workflow and eliminate fluoroscopy. Imageguided surgery incorporating augmented reality (AR) may further facilitate workflow. In this study, we developed and evaluated a protocol to integrate AR into the workflow of MISTLIF., Methods: A case series of 10 patients was the basis for the evaluation of a protocol to facilitate tubular MIS-TLIF by the application of AR. Surgical TLIF landmarks were marked on a preoperative computed tomography (CT)-scan using dedicated software. This marked CT scan was fused intraoperatively with the low-dose navigation CT scan using elastic image fusion, and the markers were transferred to the intraoperative scan. Our experience with this workflow and the surgical outcomes were collected., Results: Our AR protocol was safely implemented in all cases. The TLIF landmarks could be preoperatively planned and transferred to the intraoperative imaging. Of the 10 cases, 1 case had additionally a synovial cyst resection and in 2 cases an additional bony decompression was performed due to central stenosis. The average procedure time was 160.6 ± 31.9 minutes. The AR implementation added 1.72 ± 0.37 minutes to the overall procedure time. No complications occurred., Conclusion: Our findings support the idea that total navigation with AR may further facilitate the workflow, especially in cases with more complex anatomy and for teaching and training purposes. More work is needed to simplify the software and make AR integration more user-friendly.

Study Design: Prospective case series., Objective: SSPSS (single step pedicle screw system) was developed for minimally invasive spine surgery. We performed this study to report on safety, workflow, and our initial clinical experience with this novel technique., Methods: The prospective study was conducted on patients who underwent pedicle screw fixation between October 2017 and April 2018 using a novel single step 3D navigated pedicle screw system for MIS. Outcome measurements were obtained from intraoperative computerized tomography. The images were evaluated to determine pedicle wall penetration. We used a grading system to assess the severity of the pedicle wall penetration. Breaches were classified as grade 1 (<2 mm), grade 2 (2-4 mm), or grade 3 (<4 mm), 1 and as cranial, caudal, medial, and lateral., Results: Our study includes 135 screws in 24 patients. SSPSS eliminated K-wires and multiple steps traditionally necessary for MIS pedicle screw insertion. The median time per screw was 2.45 minutes. 3 screws were corrected intraoperatively. Pedicle wall penetration occurred in 14 screws (10%). Grade 1 breaches occurred in 4 screws (3%) and grade 2 breaches occurred in 10 screws (7%). Lateral breaches were observed more often than medial breaches. The accuracy rate in our study was 90% (Grade 0 breach). No revision surgeries were needed and no complications occurred., Conclusions: Our study suggests that SSPSS could be a safe, accurate, and efficient tool. Our accuracy rate is comparable to that found in the literature.

Background: Disk herniations that obstruct the spinal canal by more than 50% are named "giant disk herniations" (GDHs). GDHs are challenging to treat from a surgical perspective because of their size and the risk of iatrogenic manipulation during resection resulting in additional neurological compromise. As a result, the appropriateness of minimally invasive tubular approaches for the treatment of lumbar GDHs remains controversial., Objective: To report our experience in treating lumbar GDHs using tubular minimally invasive surgery., Methods: A total number of 228 disk herniations were evaluated for the criteria of GDH. In addition, the presence of neurological deficits such as cauda equina syndrome, pain as measured by a visual analog scale, operating time, complications, estimated intraoperative blood loss, and number of surgical revisions were assessed. The standard tubular diskectomy technique was modified to include unilateral laminectomy for bilateral decompression before the diskectomy to create a sufficient working space for removal of the disk fragments., Results: Twenty-three (10%) patients met the criteria for GDH. Clinically significant motor weakness was present in 21 patients (91.3%) before surgery, and 3 patients (13%) presented with cauda equina syndrome. The average mean visual analog scale (±SD) for the preoperative pain score was 8.3 and decreased to 2.4 at follow-up after surgery. All cases of cauda equina syndrome resolved postoperatively., Conclusion: Unilateral tubular minimally invasive surgery diskectomy seems to be a safe and effective treatment alternative for lumbar GDHs, combined with the "over-the-top" decompression, which provides bilateral decompression and working space., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Background: Optimal management of anti-CD20-treated patients with multiple sclerosis (pwMS) is an important clinical task during the current severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic., Objectives: To characterize humoral and cellular immune responses to SARS-CoV-2 vaccinations/infections in a longitudinal cohort of anti-CD20 treated ( n  = 175) and anti-CD20 therapy-naïve ( n  = 41) pwMS., Methods: Anti-SARS-CoV-2 spike protein immunoglobulin G (IgG) and IgA, virus neutralizing capacity, IgG avidity and SARS-CoV-2-specific T cells were determined., Results: Following two SARS-CoV-2 vaccinations, not only SARS-CoV-2 spike protein IgG and IgA, but also neutralizing capacity and avidity of SARS-CoV-2 IgG were lower in anti-CD20-treated ( n  = 51) than in anti-CD20 therapy-naïve pwMS ( n  = 14) and in healthy controls (HC, n  = 19). However, in all anti-CD20-treated pwMS vaccinated twice ( n  = 26) or infected with SARS-CoV-2 ( n  = 2), in whom SARS-CoV-2-specific T cells were measured, SARS-CoV-2-specific T cells were detectable, at levels similar to those of twice-vaccinated anti-CD20 therapy-naïve pwMS ( n  = 7) and HC ( n  = 19). SARS-CoV-2-S1 IgG levels ( r  = 0.42, p  = 0.002), antibody avidity ( r  = 0.7, p  < 0.001), and neutralizing capacity ( r  = 0.44, p  = 0.03) increased with time between anti-CD20 infusion and second vaccination. Based on detection of SARS-CoV-2 antibodies, SARS-CoV-2 infections occurred in 4 out of 175 (2.3%) anti-CD20-treated pwMS, all of whom recovered fully., Conclusions: These findings should inform treatment decisions and SARS-CoV-2 vaccination management in pwMS.

Mining is responsible for drastic ecosystem changes and rehabilitation is used to promote the return of functions after these impacts. In this scenario, we investigated the responses of ant assemblages and diaspore removal by ants to the transformations caused by mining and rehabilitation predicting that (a) the increase in plant density (a proxy for mining intensity) led to an increase in ant richness, percentage of diaspores removed, and changes in species composition that in turn are correlated with changes in environmental variables; (b) the increase in vegetation structure (a proxy for rehabilitation ages) led to an increase in ant richness, percentage of diaspores removed, and changes in species composition that in turn are correlated with changes in environmental variables. Additionally, we also verified which functional groups were primarily responsible for diaspore removal. We sampled arboreal and epigeic ants, diaspore removal by ants, and environmental variables. We found that ant richness and diaspore removal in mining intensity gradient are positively correlated to plant density. Although vegetation structure is positively correlated with ant richness, we found no changes in diaspore removal in rehabilitation gradient. Epigeic omnivore and epigeic generalist predator ants were the most responsible for diaspore removal. Then, we observed that mining decreases ant richness, altering ant assemblages and their functions, and rehabilitation with exotic plants is ineffective to promote the colonization by the main diaspore-removing ants.

Background: For complex spinal cases, especially when robotic guidance is used, preoperative planning of pedicle screws can be helpful. Transfer of these preoperatively planned pedicle screws to intraoperative 3-dimensional imaging is challenging because of changes in anatomic alignment between preoperative supine and intraoperative prone imaging, especially when multiple levels are involved. In the spine, where each individual vertebra is subject to independent movement from adjacent level, rigid image fusion is confined to a single vertebra and can display fusion inaccuracies on adjacent levels. A novel elastic fusion algorithm is introduced to overcome these disadvantages. This study aimed to investigate image registration accuracy of preoperatively planned pedicle screws with an elastic fusion algorithm vs. rigid fusion for intraoperative placement with image-guided surgery., Methods: A total of 12 patients, were selected depending on the availability of a preoperative spinal computed tomography (CT) and an intraoperative AIRO CT scan (BrainLAB AG, Munich, Germany) of the same spinal region. To verify accuracy differences between rigid fusion and elastic fusion 76 bilateral screw trajectories were virtually defined in the preoperative CT image, and they were transferred via either rigid fusion or elastic fusion to the intraoperative CT scan. Accuracy of the transferred screws in the rigid and elastic fusion group was determined by measuring pedicle breaches on the intraoperative CT., Results: In the rigid fusion group 1.3% of screws showed a breach of less than 2 mm, 9.2% showed breaches between 2 and 4 mm, and 18.4% of the screws showed an error above 4 mm. The elastic fusion group showed no breaches and provided high accuracy between preoperative and intraoperative screw placement., Conclusion: Elastic fusion provides high registration accuracy and represents a considerable step towards efficiency and safety in CT-based image-guided surgery., Level of Evidence: 3., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2021 ISASS.)

Minimally invasive posterior cervical foraminotomy (MPCF) has shown comparable outcomes to those of an open approach, with shorter operation times and length of hospital stays, as well as decreased blood loss and inpatient analgesic use. This surgical technique is mainly used to treat unilateral radiculopathy due to foraminal soft disc fragments or bone spurs. Three-dimensional (3D) navigation-guidance facilitates the surgical workflow, and it is utilized in planning the incision, determining the extent of the medial facetectomy, and confirming sufficient decompression, especially in the lower cervical spine and cervicothoracic junction, where the shoulders make localization with fluoroscopy difficult. In this video, we present the case of a 49-yr-old male patient with mechanical neck pain and C8 radiculopathy due to multilevel cervical spinal stenosis with disc herniations and C7-T1 right-sided foraminal stenosis. There was loss of cervical lordosis at the upper levels. The patient underwent anterior cervical discectomy and fusion (ACDF) at the C4-5, C5-6, and C6-7 levels to treat mechanical neck pain and restore lordosis. In order to avoid an extra-level fusion and preserve motion, we performed a right-sided C7-T1 MPCF using a portable intraoperative computed tomography (iCT) scanner (Airo®; Brainlab AG, Feldkirchen, Germany), combined with 3D computer navigation to address the patient's radicular symptoms. Patient consent was obtained prior to performing the procedure., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Intraoperative image-guidance in spinal surgery has been influenced by various technological developments in imaging science since the early 1990s. The technology has evolved from simple fluoroscopic-based guidance to state-of-art intraoperative computed tomography (iCT)-based navigation systems. Although the intraoperative navigation is more commonly used in thoracolumbar spine surgery, this newer imaging platform has rapidly gained popularity in cervical approaches. The purpose of this manuscript is to address the applications of advanced image-guidance in cervical spine surgery and to describe the use of intraoperative neuro-navigation in surgical planning and execution. In this review, we aim to cover the following surgical techniques: anterior cervical approaches, atlanto-axial fixation, subaxial instrumentation, percutaneous interfacet cage implantation as well as minimally invasive posterior cervical foraminotomy (PCF) and unilateral laminotomy for bilateral decompression. The currently available data suggested that the use of 3D navigation significantly reduces the screw malposition, operative time, mean blood loss, radiation exposure, and complication rates in comparison to the conventional fluoroscopic-guidance. With the advancements in technology and surgical techniques, 3D navigation has potential to replace conventional fluoroscopy completely., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-1101). The series “Current State of Intraoperative Imaging” was commissioned by the editorial office without any funding or sponsorship. RH reports that he is a consultant for Ulrich, Brainlab, DePuy-Synthes and he has royalties from Zimmer. The authors have no other conflicts of interest to declare., (2021 Annals of Translational Medicine. All rights reserved.)

Aims: To explore differences in advanced brain magnetic resonance imaging (MRI) characteristics between myelin oligodendrocyte (MOG) immunoglobulin (IgG) and aquaporin-4 (AQP4) IgG seropositive (+) neuromyelitis optica spectrum disorders (NMOSD). Methods: 33 AQP4-IgG and 18 MOG-IgG seropositive NMOSD patients and 61 healthy control (HC) subjects were included. All 112 participants were scanned with the same standardized MRI-protocol on a 3-Tesla MRI-scanner. Brain volume and diffusion tensor imaging (DTI) parameters were assessed. Results: MOG-IgG+ patients showed reduced parallel diffusivity within white matter tracts compared to HC whereas AQP4-IgG+ showed no significant brain parenchymal damage in DTI analysis. AQP4-IgG+ patients showed reduced whole brain volumes and reduced volumes of several deep gray matter structures compared to HC whereas MOG-IgG+ patients did not show reduced brain or deep gray matter volumes compared to HC. Conclusions: Microstructural brain parenchymal damage in MOG-IgG+ patients was more pronounced than in AQP4-IgG+ patients, compared with HC, whereas normalized brain volume reduction was more severe in AQP4-IgG+ patients. Longitudinal imaging studies are warranted to further investigate this trend in NMOSD. Our results suggest that MOG-IgG+ and AQP4-IgG+ NMOSD patients differ in cerebral MRI characteristics. Advanced MRI analysis did not help to differentiate between MOG-IgG+ and AQP4-IgG+ patients in our study., (Copyright © 2020 Schmidt, Chien, Kuchling, Bellmann-Strobl, Ruprecht, Siebert, Asseyer, Jarius, Brandt, Scheel and Paul.)

This video demonstrates the step-by-step surgical technique for a less invasive cervical unilateral laminotomy for bilateral decompression (cervical ULBD). This technique allows surgeons to address bilateral cervical pathology while minimizing approach-related complications.1 In the video, we present the case of a 72-yr-old female patient with a past medical history of C3-C4 anterior cervical discectomy and fusion who presented in clinic with persistent posterior spinal cord compression and signal change. The patient had bilateral hand numbness, weakness, poor dexterity, and a positive Hoffman's sign. The patient was treated via a C3-C4 less invasive cervical ULBD using a mobile 3-dimensional (3D) C-arm (Ziehm Vision RFD 3D®, Nürnberg, Germany) combined with 3D computer navigation. Patient consent was obtained prior to performing the procedure. Contrary to anterior techniques, posterior cervical approaches avoid potential dysphasia, recurrent laryngeal nerve injury, and adjacent segment degeneration. Furthermore, the less invasive cervical ULBD results in decreased pain and postoperative narcotic usage, shorter hospital stays and fewer infections compared to open approaches, as well as a lower risk for postlaminectomy kyphosis and deformity, since it requires less muscle disruption and bony removal. Additionally, the use of total 3D navigation facilitates the workflow and minimizes radiation exposure., (Copyright © 2020 by the Congress of Neurological Surgeons.)

This video demonstrates the step-by-step surgical technique for the minimally invasive laminotomy for contralateral "over-the-top" foraminal decompression. This technique allows for excellent decompression with clearance of the contralateral recess and foramen. In the video, we present the case of a 51-yr-old female patient with a past medical history of left L5-S1 microdiscectomy who presented in clinic with residual/recurrent foraminal disc herniation at L5-S1 compressing the left L5 nerve root. The patient had left lower extremity pain in the left hip and thigh that radiated down the front and side of the leg, as well as tingling and numbness in the left foot. The patient was treated via a L5-S1 microdiscectomy using a portable intraoperative computed tomography scanner, (Airo®, Brainlab AG, Feldkirchen, Germany), combined with 3-dimensional (3D) computer navigation. Patient consent was obtained prior to performing the procedure. The main advantage of this technique is the direct "over-the-top" trajectory to the foraminal pathology that minimizes the need of facet joint resection. The use of 3D navigation facilitates surgical planning and further minimizes facet joint compromise. Particularly, the inferior facet contralateral to the approach side as well as its outer capsular surroundings can be preserved. Recent biomechanical studies have shown that "over-the-top" decompression produces significantly less instability than a traditional open midline laminectomy., (Copyright © 2019 by the Congress of Neurological Surgeons.)

This paper provides a detailed report of Global Neurosurgery 2019: A Practical Symposium held January 18-19, 2019, at Weill Cornell Medical College, New York, New York, USA. The meeting convened an international faculty and audience, leaders in the world of global neurosurgery (GNS), and junior faculty and residents beginning their contribution to the field. Remote access for the symposium was provided to include faculty practicing in developing countries. The goal of the symposium was to present the state of the union of GNS initiatives worldwide, to use this forum as a means to centralize resources and converge parallel efforts, and to identify the largest areas of need and successful means of advancing training and care in these areas. The meeting also served as a conduit for the presentation of funding and training opportunities for junior faculty and trainees looking for avenues to gain support and mentorship in pursuing academic and clinical endeavors globally., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Innovative technology and techniques have revolutionized minimally invasive spine surgery (MIS) within the past decade. The introduction of navigation and image-guided surgery has greatly affected spinal surgery and will continue to make surgery safer and more efficient. Eventually, it is conceivable that fluoroscopy will be completely replaced with image guidance. These advancements, among others such as robotics and virtual and augmented reality technology, will continue to drive the value of 3-dimensional navigation in MIS. In this review, we cover pertinent features of navigation in MIS and explore their evolution over time. Moreover, we aim to discuss the key features germane to surgical advancement, including technique and technology development, accuracy, overall health care costs, operating room time efficiency, and radiation exposure., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RH is a consultant for Ulrich, Brainlab, DePuy-Synthes, and has royalties from Zimmer. The other authors have no disclosures., (© The Author(s) 2020.)

Study Design: Systematic review., Objective: To date there is no consensus among surgeons as to what defines an MIS-TLIF (transforaminal lumbar interbody fusion using minimally invasive spine surgery) compared to an open or mini-open TLIF. This systematic review aimed to examine the MIS-TLIF techniques reported in the recent body of literature to help provide a definition of what constitutes the MIS-TLIF, based on the consensus of the majority of surgeons., Methods: We created a database of articles published about MIS-TLIF between 2010 and 2018. We evaluated the technical components of the MIS-TLIF including instruments and incisions used as well the order in which key steps are performed., Results: We could identify several patterns for MIS-TLIF performance that seemed agreed upon by the majority of MIS surgeons: use of paramedian incisions; use of a tubular retractor to perform a total facetectomy, decompression, and interbody cage implantation; and percutaneous insertion of the pedicle-screw rod constructs with intraoperative imaging., Conclusion: Based on this review of the literature, the key features used by surgeons performing MIS TLIF include the use of nonexpandable or expandable tubular retractors, a paramedian or lateral incision, and the use of a microscope or endoscope for visualization. Approaches using expandable nontubular retractors, those that require extensive subperiosteal dissection from the midline laterally, or specular-based retractors with wide pedicle to pedicle exposure are far less likely to be promoted as an MIS-based approach. A definition is necessary to improve the communication among spine surgeons in research as well as patient education., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RH has received funding from AOSpine, Brainlab, DePuy Synthes, Lanx, and the Carol and Grace Hansen Spinal Research Foundation. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article., (© The Author(s) 2019.)

Background: In patients with symptomatic lumbar stenosis undergoing lateral transpsoas approach for lumbar interbody fusion (LLIF) surgery, it is not always clear when indirect decompression is sufficient in order to achieve symptom resolution. Indirect decompression failure (IDF), defined as "postoperative persistent symptoms of nerve compression with or without a second direct decompression surgery to reach adequate symptom resolution," is not widely reported. This information, however, is critical to better understand the indications, the potential, and the limitations of indirect decompression., Objective: The purpose of this study was to systematically review the current literature on IDF after LLIF., Methods: A literature search was performed on PubMed. We included randomized controlled trials and prospective, retrospective, case-control studies, and case reports. Information on sample size, demographics, procedure, number and location of involved levels, follow-up time, and complications were extracted., Results: After applying the exclusion criteria, we included 9 of the 268 screened articles that reported failure. A total of 632 patients were screened in these articles and detailed information was provided. Average follow-up time was 21 months. Overall reported incidence of IDF was 9%., Conclusion: Failures of decompression via LLIF are inconsistently reported and the incidence is approximately 9%. IDF failure in LLIF may be underreported or misinterpreted as a complication. We propose to include the term "IDF" as described in this article to differentiate them from complications for future studies. A better understanding of why IDF occurs will allow surgeons to better plan surgical intervention and will avoid revision surgery., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Roger Härtl is a consultant for Ulrich, Brainlab, DePuy-Synthes, and he has royalties from Zimmer. The other authors have no conflicts of interest to disclose., (© The Author(s) 2019.)

The purpose of this review is to describe how a curriculum for minimally invasive spine surgery (MISS) was developed and implemented. The authors discuss the curriculum roadmap, its target audience, and the educational process for teaching general skills and specific procedures in MISS. Initiated by AOSpine, a panel of experts within spinal surgery from multiple centers formed the minimally invasive spine surgery task force. Together, task force members redefined the standards and milestones of the MISS education and training. Therefore, we conclude that the MISS task force created a structured curriculum which will have a positive influence on daily practice for surgeons and patients worldwide., Competing Interests: Declaration of Conflicting Interests: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: RH has received funding from AOSpine, Brainlab, DePuy Synthes, Lanx., (© The Author(s) 2020.)

Study Design: Case studies., Objectives: To demonstrate that muscle generated pain (MGP) may be a cause of pain in patients who have undergone minimally invasive spine surgery (MISS)., Methods: A physical examination including electrical stimulation of putative pain generating muscles to identify the presence of lowered thresholds for depolarization of muscle nociceptors, and an examination of strength and flexibility of key muscles in the upper and lower body, may identify multiple etiologies of MGP. Treatment of identified muscles consisted of muscle/tendon injections to identified sensitized muscles followed by exercises incorporating relaxation limbering and stretching., Results: Postsurgical pain was eliminated and mobility restored in both presented cases replicating success in prior published studies., Conclusions: Understanding the pathophysiological mechanisms of muscle pain may facilitate the evaluation and treatment of MGP in MISS patients diagnosed with failed back surgery syndrome., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Study Design: Technical note, retrospective case series., Objective: Lumbar stenosis can be effectively treated using tubular unilateral laminotomy for bilateral decompression (ULBD). For multilevel stenosis, a multilevel ULBD through separate, alternating crossover approaches has been described as the "slalom technique." To increase efficacy, we introduced this approach with 2 microscopes simultaneously., Methods: We collected data on 13 patients, with multilevel lumbar stenosis, operated at our institution between 2015 and 2016 by the aforementioned technique. We assessed surgical time (ST), estimated blood loss (EBL), complications, and revision surgeries. Furthermore, we provide a stepwise instruction for performing the tandem microscopic slalom technique in a safe and efficient manner., Results: The mean age of the patients was 68 ± 8 years. The ST per level was 68 ± 19 minutes with an EBL per level of 39 ± 30 mL. We had no intraoperative complications and none of our patients required a revision surgery during a mean follow-up of 12 months., Conclusions: We have shown that this technique is feasible and can be performed safely for multisegmental lumbar spinal stenosis with minimal tissue trauma and low EBL. Furthermore, randomized controlled studies with a larger sample size may be necessary to drive any final conclusions., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Roger Härtl receives consultant fees from DePuy Synthes, Brainlab, and Ulrich and royalties from Zimmer Biomet., (© The Author(s) 2019.)

Background: Minimally invasive techniques utilizing tubular retractors have become an increasingly popular approach to the spinal column. The concept of a unilateral laminotomy for bilateral decompression (ULBD), first applied in the lumbar spine, has recently been applied to the cervical spine for the treatment of cervical spondylotic myelopathy (CSM). A better understanding of the indications and surgical techniques is required to effectively educate surgeons on how to appropriately and safely perform tubular cervical laminotomy via ULBD., Objective: To describe a 10-step technique for minimally invasive cervical laminotomy and report our early clinical experience., Methods: A retrospective review identified 15 patients with CSM who were treated with this procedure. Visual analogue scale (VAS), neck disability index (NDI), and modified Japanese Orthopaedic Association (mJOA) scores were obtained pre- and postoperatively., Results: The mean age of the 15 patients was 73.1 ± 6.8 yr. The median number of levels treated was 1 (range 1-3). Mean operative time was 125.3 ± 30.8 or 81.7 ± 19.2 min per level. Mean estimated blood loss was 57.3 ± 24.6 cc. Median postoperative hospital length of stay was 36 h. No complications were encountered. Median follow-up was 18 mo. Mean pre- and postoperative VAS were 6.4 ± 2.4 and 1.0 ± 0.8, respectively (P < .001). Mean pre- and postoperative NDI were 46.4 ± 19.2 and 7.0 ± 6.9, respectively (P < .001). Mean pre- and postoperative Mjoa were 11.3 ± 2.5 and 14.5 ± 0.5, respectively (P < .001)., Conclusion: In our early clinical experience, minimally invasive cervical ULBD is safe and effective. Adherence to the presented 10-step technique will allow surgeons to safely address bilateral cervical pathology while avoiding complications., (Copyright © 2019 by the Congress of Neurological Surgeons.)

This video demonstrates the workflow of a minimally invasive transforaminal interbody fusion (MIS-TLIF) using a portable intraoperative CT (iCT) scanner, (Airo®, Brainlab AG, Feldkirchen, Germany), combined with state-of-the-art total 3D computer navigation. The navigation is used not only for instrumentation but also for intraoperative planning throughout the procedure, inserting the cage, therefore, completely eliminating the need for fluoroscopy. In this video, we present a case of a 72-yr-old female patient with a history of lower back pain, right lower extremity radicular pain and weakness for 2 yr due to L4-L5 spondylolisthesis with instability and severe lumbar spinal stenosis. The patient is treated by a L4-L5 unilateral laminotomy for bilateral decompression (ULBD) and MIS-TLIF. MIS-TLIF using total 3D navigation significantly improves the workflow of the conventional TLIF procedure. The tailored access to the spine is translated into smaller but more efficient surgical corridors. This modification in a "total navigation" modality minimizes the staff radiation exposure to 0 by navigating in real time over iCT obtained images that can be acquired while the surgical staff is protected or outside the OR. Furthermore, this technique makes real-time and virtual intraoperative imaging of screws and their planned trajectory feasible. 3D Navigation eliminates the need for K-Wires, thus decreasing the risk of vascular penetration injury due to K-Wire malpositioning. 3D navigation can also predict the positioning of the interbody cage, thereby, decreasing the risk of malpositioning or subsidence. Patient consent was obtained prior to performing the procedure., (Copyright © 2019 by the Congress of Neurological Surgeons.)

The peculiarity of extreme lateral interbody fusion (LLIF) is the achievement of indirect neural decompression of the spinal canal while distracting the intervertebral disc space using an interbody cage. In this manuscript we will review the potentials and limitations of this technique when treating degenerative disc disease of the lumbar spine. A literature search of the PubMed-National Library of Medicine was performed. Only articles in English were included. The current available literature demonstrates that LLIF is an effective method to decompress foraminal and central canal stenosis. Based on the current available literature LLIF effects on lateral recess stenosis are less consistent. The aim of this review is to provide with a thorough overview of the latest literature available and provide the audience with targeted-oriented published results that will eventually improve the decision-making process when using the LLIF technique.

Minimally invasive surgical approaches for the treatment of spinal pathologies have accelerated over the past three decades and resulted in superior functional outcomes with less complications. Yet cervical pathologies have been slower to gain traction for multiple anatomical factors and its "high-risk" profile. Various minimally invasive techniques for cervical disease have now been described and validated in long-term studies with comparable outcomes to traditional open approaches and concomitant reduction in morbidity and socioeconomic costs. Transnasal operations can be used to treat ventral upper cervical disease, circumventing traditional and morbid transoral approaches. Posterior-based focused treatments for radiculopathy and myelopathy such as tubular-guided foraminotomies and unilateral laminotomies for bilateral cord decompression have also been described and becoming increasingly less invasive. Cervical fusions can now be performed percutaneously through modified, stand-alone facet joint cages that can be packed with allogeneic bone graft. These advances have been facilitated by the development of intraoperative imaging technologies (intraoperative CT) and 3-dimensional stereotactic navigation software. While this review focuses on these procedures and evidence-based outcomes data, the future for MIS applications in cervical spine surgery will continue to evolve over the coming years with wider indications and technological adjuncts., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: To test the hypothesis that olfactory (OF) and gustatory function (GF) is disturbed in patients with autoimmune encephalitides (AE). Methods: The orthonasal OF was tested in 32 patients with AE and 32 age- and sex-matched healthy controls (HC) with the standardized Threshold Discrimination Identification (TDI) score. This validated olfactory testing method yields individual scores for olfactory threshold (T), odor discrimination (D), and identification (I), along with a composite TDI score. The GF was determined by the Taste Strip Test (TST). Results: Overall, 24/32 (75%) of patients with AE, but none of 32 HC ( p < 0.001) had olfactory dysfunction in TDI testing. The results of the threshold, discrimination and identification subtests were significantly reduced in patients with AE compared to HC (all p < 0.001). Assessed by TST, 5/19 (26.3%) of patients with AE, but none of 19 HC presented a significant limitation in GF ( p < 0.001). The TDI score was correlated with the subjective estimation of the olfactory capacity on a visual analog scale (VAS; r s = 0.475, p = 0.008). Neither age, sex, modified Rankin Scale nor disease duration were associated with the composite TDI score. Conclusions: This is the first study investigating OF and GF in AE patients. According to unblinded assessment, patients with AE have a reduced olfactory and gustatory capacity compared to HC, suggesting that olfactory and gustatory dysfunction are hitherto unrecognized symptoms in AE. Further studies with larger number of AE patients would be of interest to verify our results.

Background: Bow hunter syndrome describes a mechanical compression of the vertebral artery on head rotation leading to reversible symptomatic vertebrobasilar insufficiency. Patients are commonly presenting with syncope, vertigo, dizziness, and visual disturbances. These symptoms usually resolve when the head is turned back into neutral position. Treatment options involve surgical decompression with or without fusion, bypass surgery, or endovascular intervention., Case Description: We report about a 49-year-old female who presented with vague neck pain and severe vertigo, nausea, and near syncope when her head turned up and right. Computed tomography angiography revealed a pseudoaneurysm at the dominant left V3 and near total occlusion of the left vertebral artery as it exited the C2 foramen when the head was turned to the previously mentioned position. The patient could be successfully treated by computed tomography-navigated posterior instrumentation using bilateral C1 lateral mass screws and C2 translaminar screws. To promote segmental fusion, bilateral intrafacet cages were implanted. Postoperatively, the patient remained without neurologic deficits and experienced no further episodes of the preoperatively reported transient vertebrobasilar insufficiency symptoms., Conclusions: The reported case is unique as the bow hunter syndrome was further complicated by a pseudoaneurysm of the V3 segment. Surgical intervention proved to be an efficient treatment by stabilizing the affected segment in this patient., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Context: The concept of dynamic stabilization (DS) of the lumbar spine for treatment of degenerative instability has been introduced almost two decades ago. Dynamic stabilization follows the principle of controlling movement in the coronal plane by providing load transfer of the spinal segment without fusion and, at the same time, reducing side effects such as adjacent segment disease (ASD). So far, only little is known about revision rates after DS due to ASD and screw loosening (SL)., Purpose: The present study aimed to evaluate the longitudinal revision rates following dynamic pedicle screw stabilization in the lumbar spine and to determine specific risk factors predictive for ASD, SL, and overall reoperation in a large cohort with considerable follow-up., Design: We carried out a post hoc analysis of a prospectively collected database in a level I spine center., Patients Example: The patient sample comprised 283 (151 female/132 male) consecutive patients suffering from painful degenerative lumbar segmental instability with or without spinal stenosis who underwent DS of the lumbar spine (Ulrich Cosmic, Ulrich Medical, Ulm, Germany) between January 2008 and December 2011., Outcome Measures: Longitudinal reoperation rate and risk factors predictive for revision surgery were evaluated., Methods: We analyzed the longitudinal reoperation rate due to ASD and SL and overall reoperation. Risk factors such as age, gender, body mass index, lumbar lordosis (LL), number of segments, and number of previous surgeries were taken into account. Regular and mixed model logistic regressions were performed to determine risk factors for revision surgery on a patient and on a screw level., Results: The mean age was 65.7±10.2 years (range 31-88). One hundred thirty-two patients were stabilized in 1 segment, 134 in 2 segments, 15 in 3 segments, and 2 patients in 4 segments. Reoperation rate for ASD and SL after 1 year was 7.4 %, after 2 years was 15.0%, and after a mean follow-up of 51.4±15 months was 22.6%. Reasons for revision were SL in 19 cases (6.6%), ASD in 39 cases (13.7%), SL and ASD in 6 cases, hematoma in 2 cases (0.7%), cerebrospinal fluid fistulae in 3 cases (1.1%), infection in 6 cases (2.1%), and implant failure in 1 case (0.4%). The patients' age, the number of stabilized segments, and the number of previous surgeries and postoperative LL had a significant influence on the probability for revision surgery., Conclusions: Reoperation rates after DS of the lumbar spine are comparable with rigid fixations. The younger the patient and the more segments are involved, the lower the LL and the more previous surgeries were found, the higher was the risk of revision. Risk of revision was almost twice as high in men compared with women. We therefore conclude that for clear clinical indication and careful evaluation of preoperative imaging data, DS using the Cosmic system seems to be a possible option. The presented data will help to further tailor indication and patient selection., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Symptomatic lumbar spondylolisthesis is commonly accompanied by spinal stenosis in multiple segments. These pathologies are routinely treated by multilevel decompression and instrumented fusion. However, it was hypothesized that a minimally invasive surgery (MIS) fusion in the unstable segment combined with a unilateral laminotomy for bilateral decompression (ULBD) in the adjacent stenotic segment is a biomechanically feasible alternative to a two-level fusion and superior to open laminectomy adjacent to a fused segment. This concept has demonstrated success in a recently published biomechanical cadaver study performed by our group. The present article offers a detailed step by step technical description for an MIS-TLIF (transforaminal lumbar interbody fusion) with adjacent ULBD., Competing Interests: Conflicts of Interest: R Härtl is a consultant for DePuy-Synthes, Ulrich and Brainlab and receives royalties from Zimmer. The other authors have no conflicts of interest to declare.

Background: Superficial siderosis of the central nervous system is a rare neurologic disorder characterized by the superficial deposition of hemosiderin in the subpial layer resulting in iron-related progressive neurodegeneration., Case Description: In this report, we present a case of superficial siderosis of the central nervous system secondary to an intradural thoracic disk herniation causing a cerebrospinal fluid (CSF) leak., Conclusions: The patient was successfully treated with T6-T8 transpedicular partial corpectomy, as well as diskectomy with decompression followed by watertight closure of the CSF leak. Intraoperative watertight closure of the CSF leak was achieved., (Copyright © 2018. Published by Elsevier Inc.)

Objective: We tested the hypothesis that the maximally treated intracerebral hemorrhage (max-ICH) score is superior to the ICH score for characterizing mortality and functional outcome prognosis in patients with ICH, particularly those who receive maximal treatment., Methods: Patients presenting with spontaneous ICH were enrolled in a prospective observational study that collected demographic and clinical data. Mortality and functional outcomes were measured by using the modified Rankin Scale at 3 months. The ICH score and max-ICH score incorporate measures of symptom severity, age, hematoma volume, hematoma location, and intraventricular hemorrhage, with the max-ICH score also including a term for oral anticoagulation and having 16 score categories vs 11 for the ICH score. We compared the area under the receiver operating characteristic curve (AUC) for the ICH score and max-ICH score for both mortality and poor functional outcome, defined as modified Rankin Scale scores 4-6., Results: We analyzed outcomes for 372 patients, including 71 patients (19%) in whom care limitation/withdrawal of life support was instituted. Both the ICH score and max-ICH score showed good prognostic performance for 3-month mortality and poor functional outcomes in the full group as well as the subgroup with maximal treatment (i.e., no care limitations; AUC range 0.80-0.86), with no significant difference in AUC between the scores for either endpoint in either group., Conclusions: External validation with direct comparison of the ICH score and max-ICH score shows that their prognostic performance is not meaningfully different. Alternatives to simple scores are likely needed to improve prognostic estimates for patient care decisions., (© 2018 American Academy of Neurology.)

Purpose: To evaluate B-mode ultrasound as a novel method for objective and quantitative assessment of a relative afferent pupillary defect (RAPD) in a prospective case-control study., Methods: Seventeen patients with unilateral optic neuropathy and a clinically detectable RAPD and 17 age and sex matched healthy controls were examined with B-mode ultrasound using an Esaote-Mylab25 system according to current guidelines for orbital insonation. The swinging flashlight test was performed during ultrasound assessment with a standardized light stimulus using a penlight., Results: B-mode ultrasound RAPD examination was doable in approximately 5 minutes only and was well tolerated by all participants. Compared to the unaffected contralateral eyes, eyes with RAPD showed lower absolute constriction amplitude of the pupillary diameter (mean [SD] 0.8 [0.4] vs. 2.1 [0.4] mm; p = 0.009) and a longer pupillary constriction time after ipsilateral light stimulus (mean [SD] 1240 [180] vs. 710 [200] ms; p = 0.008). In eyes affected by RAPD, visual acuity correlated with the absolute constriction amplitude (r = 0.75, p = 0.001)., Conclusions: B-mode ultrasound enables fast, easy and objective quantification of a RAPD and can thus be applied in clinical practice to document a RAPD., Competing Interests: F Schmidt has received speaker honoraria from Genzyme, outside the submitted work. K Ruprecht has received research support from Novartis and Bundesministerium für Bildung und Forschung (Competence Network Multiple Sclerosis) as well as speaking fees or travel grants from Guthy Jackson Charitable Foundation and Biogen, outside the submitted work. F Connolly has nothing to disclose. M Maas receives funding from National Institutes of Health grants K23NS092975 and L30NS080176, and has served as a technical consultant for Hyperfine Research, outside the submitted work. F Paul reports grants from BMBF, grants from BMBF, grants from DFG, grants from GJCF, grants from Novartis, personal fees from Bayer, Teva, Genzyme, Merck, MedImmune and Novartis, outside the submitted work. L Harms has received speaker honoraria from Biogen, Teva, Bayer and Novartis. He serves on the advisory board for Roche, Novartis, Genzyme and has received travel support from Biogen, Roche, Bayer and Serono, outside the submitted work. S Schreiber has nothing to disclose. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Purpose: To evaluate B-mode ultrasound as a novel method for the examination of pupillary function and to provide normal values for the pupillary reflex as assessed by B-mode ultrasound., Methods: 100 subjects (49 female, 51 male, mean [range] age 51 [18-80 years]) with no history of ophthalmologic disease, no clinically detectable pupillary defects, and corrected visual acuity ≥ 0.8 were included in this prospective observational study. B-mode ultrasound was performed with the subjects eyes closed using an Esaote-Mylab25 system according to current guidelines for orbital insonation. A standardized light stimulus was applied., Results: The mean ± standard deviation left and right pupillary diameters (PD) at rest were 4.7 ± 0.8 and 4.5 ± 0.8 mm. Following an ipsilateral light stimulus (Lstim), left and right constricted PD were 2.8 ± 0.6 and 2.7 ± 0.6 mm. Following a contralateral Lstim, left and right constricted PD were 2.7 ± 0.6 and 2.6 ± 0.5 mm. Left and right pupillary constriction time (PCT) following ipsilateral Lstim were 970 ± 261.6 and 967 ± 220 ms. Left and right PCT following a contralateral Lstim were 993.8 ± 192.6 and 963 ± 189.4 ms. Patient age was inversely correlated with PD at rest and with PD after ipsilateral and contralateral Lstim (all p<0.001), but not with PCT., Conclusions: B-mode ultrasound is a simple, rapid and objective method for the quantitative assessment of pupillary function, which may prove useful in a variety of settings where eyelid retraction is impeded or an infrared pupillometry device is unavailable.

Local biodiversity can be expected to be similar worldwide if environmental conditions are similar. Here, we hypothesize that tropical ant communities with different types of regional species pools but at similar habitat types in Brazil and Indonesia show similar diversity patterns at multiple spatial scales, when comparing (1) the relative contribution of alpha and beta diversity to gamma diversity; (2) the number of distinct communities (community differentiation); and (3) the drivers of β-diversity (species replacement or species loss/gain) at each spatial scale. In both countries, rainforests and savannas (biome scale) were represented by three landscapes (landscape scale), each with four transects (site scale) and each transect with 10 pitfall traps (local scale). At the local scale, α-diversity was higher and β-diversity lower than expected from null models. Hence, we observed a high coexistence of species across biomes. The replacement of species seemed the most important factor for β-diversity among sites and among landscapes across biomes. Species sorting, landscape-moderated species distribution and neutral drift are potential mechanisms for the high β-diversity among sites within landscapes. At the biome scale, different evolutionary histories produced great differences in ant community composition, so the replacement of species is, at this scale, the most important driver of beta diversity. According to these key findings, we conclude that distinct regional ant species pools from similar tropical habitat types are similarly constrained across several spatial scales, regardless of the continent considered.

Objective: We tested the hypothesis that olfactory function is more impaired in patients with primary progressive MS (PPMS) than that in relapsing-remitting MS (RRMS)., Methods: Standardized olfactory testing was performed in 32 patients with PPMS, 32 patients with RRMS, and 32 healthy controls (HCs). Patients with olfactory dysfunction due to an alternative primary etiology were excluded. The validated olfactory testing method yielded individual scores for olfactory threshold, odor discrimination, and odor identification, along with a composite Threshold Discrimination Identification (TDI) score., Results: Olfactory dysfunction was identified in 27 (84%) patients with PPMS, 10 (31%) patients with RRMS, and 1 (3%) HC. While age and sex were similar between PPMS and HCs, the TDI score and all olfactory subscores were significantly worse in patients with PPMS compared with HCs (all p < 0.001). After adjustment for differences in age, sex, Expanded Disability Status Scale (EDSS), and disease duration, odor discrimination, odor identification, and the composite TDI score were worse in patients with PPMS vs RRMS ( p = 0.03, 0.04, and 0.02, respectively). Neither age, sex, EDSS, nor disease duration was significantly associated with the composite TDI score., Conclusions: Olfactory dysfunction was more frequent and severe in PPMS compared with RRMS, independent of disease duration and overall disability status. Further research on cellular level differences in olfactory neural pathways may lead to new insights about disease pathogenesis in MS.

Background: The aim of the study was to investigate changes of the olfactory and gustatory capacity in patients with multiple sclerosis (MS)., Methodology: 20 MS patients were tested longitudinally for 3 years after initial testing. The Threshold Discrimination Identification test (TDI) was used for subjective olfactometry. Objective olfactometry was performed by registering olfactory evoked potentials (OEP) by EEG. The Taste Strip Test (TST) was used for gustatory testing., Results: 45% of the patients showed olfactory dysfunction in the follow-up TDI test and 50% showed delayed OEP´s. 20% of the patients showed gustatory dysfunction on follow-up visit. The patients showed mild disease activity with 0,3 ± 0,5 relapses over the testing period and no significant change of their olfactory and gustatory capacity. The olfactory capacity for the discrimination of odors correlated inversely with the number of relapses (r = -0.5, p ≤ 0.05). The patients were aware of their olfactory deficit., Conclusions: Olfactory and gustatory dysfunction is a symptom in MS patients and may be a useful parameter to estimate disease progression in MS patients. As the discrimination of odors is processed in higher central regions of the central nervous system (CNS), the results suggest that olfactory dysfunction could be due to CNS damage., Competing Interests: The authors have declared that no competing interests exist.

Data from five experiments with dairy cows where feed was restricted to 0, 40, and 50% of the ad libitum amount, with 259 observations, were subjected to multivariate analyses to determine the effects of severity and duration of feed restriction on production, physical-chemical characteristics, ethanol stability, and somatic cell score of milk. A negative relationship was seen between the severity and duration of feed restriction with milk production, lactose content, titratable acidity, and milk stability to the ethanol test. The milk stability to the ethanol test, protein content, milk yield, and somatic cells score were the most important attributes retained by the discriminant analysis. Milk stability to the ethanol test, live weight, days in restriction, and pH were the most important characteristics explaining the variance within the different levels of feed restriction. Milk production and ethanol stability were significantly lower in both levels of feed restriction compared with the group fed ad libitum. When feed restriction was followed by refeeding, the difference observed in ethanol stability was the first discriminant variable, followed by the difference in unstable milk frequency and titratable acidity. Increments in the severity and duration of feed restriction negatively affect milk production and milk ethanol stability.

The aim of this research was to evaluate the risk factors for new and chronic subclinical intramammary infections (IMI) using the monthly somatic cells count of dairy cows. The study took place at 30 dairy herds with approximately 1,700 cows in lactation. Data characterizing the dairy farms and their milking management were obtained from a survey questionnaire. The somatic cells count values from 2 consecutive months were used to classify cows as either healthy or with new or chronic infections. A chi-squared test was used in the analysis of subclinical IMI to evaluate associations between each independent variable, followed by logistic regression to estimate the risk of a new infection in healthy cows and of chronic infection in cows with new infections. Factors increasing the odds ratio of a cow developing a new case of subclinical mastitis were (1) cows with more than 3 lactations, (2) cows with a mean hyperkeratosis score above 3, (3) cows with the udder below the hock, (4) cows with very dirty udders, and (5) milking of infected animals before healthy cows. Factors increasing the risk of a subclinical chronic infection compared with new cases of subclinical mastitis were (1) a lack of regular maintenance of milking machinery, (2) cows over 100 d in lactation, and (3) cows with the udder on or below the hock. The risk factors identified in this study can be used in IMI control programs to reduce the frequency of new and chronic cases of subclinical mastitis., (Copyright © 2015 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

The effect of shade on behavior and physiological attributes of grazing cows in a high altitude subtropical zone is not well established. This work aimed to investigate how social and ingestive behaviors, as well as physiological and other attributes of dairy cows such as milk production, change in a subtropical environment during the hot season either with or without free access to shade. Fourteen lactating cows were kept on pasture either with no shade or with free access to shade for 5 days and their behavior was recorded with instantaneous scan sampled every 10 min, from sunrise, 0530 h (Greenwich mean time, GMT-0200 h) to sunset, 2100 h (GMT-0200 h). Behavior traits included (1) time spent in activities such as grazing, ruminating, resting, lying, standing, walking, seeking shade and staying in the proximity to the water trough and (2) number of events such as water ingestion, aggressive interactions, as well as competition for shade and water. Physiological attributes such as heart and respiratory rates, rectal temperature, number of rumen movements, panting score, as well as milk yield, were evaluated. Time spent in behavioral activities, number of behavioral events and physiological attributes varied between groups (with and without access to shade). Cows with no shade showed increased respiratory and heart rates and panting score at 1300 h, higher values for time of permanence near the water trough, number of competition and aggression events for shade. On the other hand, they showed lower values for time spent resting while lying, ruminating while standing, seeking shade. Access to shade did not change time spent lying, standing, walking with the head up, ruminating while lying, resting while standing, as well as milk yield and number of ruminal movements. Significant interactions between access to shade and days of measurements were detected for time spent walking, ruminating, grazing, resting, number of water ingestion events, competition events near the water trough and for shade, as well as for rectal temperature and panting score measured at 1700 h. In the high altitude subtropical region, access to shade minimizes negative heat stress effects on behavior and physiological aspects of dairy cows.

Aim: Due to their high rate of neo-angiogenesis, malignant gliomas may qualify for treatment with anti-angiogenic substances. We report on a series of patients with malignant glioma not eligible for standard postoperative combined radiochemotherapy due to decreased health status., Patients and Methods: A total of nine patients with malignant glioma, postoperatively presenting with a Karnofsky performance score (KPS) below 70, were treated with standalone metronomic low-dose chemotherapy with temozolomide and celecoxib (cyclo-oxygenase-2 inhibitor). Overall survival was defined as the primary end-point and the functional status (KPS) and time to progression as secondary end-points of our analysis., Results: The median KPS after surgery was 60. Treatment achieved a decrease in tumor and edema volume and, more importantly, preserved the functional status defined as the ability to care for self (KPS 70%) until disease progression. No notable side-effects were recorded., Conclusion: In patients with decreased general condition (KPS <70), not eligible for standard treatment, anti-angiogenic therapy offers a reasonable alternative approach. Our results indicate prolonged survival and preserved quality of life in comparison to best supportive care., (Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Purpose: To investigate diffusion tensor abnormalities, e.g. fractional anisotropy (FA), mean diffusivity (MD), and radial diffusivity (RD), in olfactory structures of multiple sclerosis (MS) patients using diffusion tensor imaging (DTI)., Methods: Institutional review board-approved prospective study on 30 MS patients and 12 healthy controls investigated with MRI including DTI. Central olfactory structures were labelled on each patient's and healthy contro''s DTI volume. The diffusion tensor was determined in the central olfactory structures in MS patients. Tract-based spatial statistics (TBSS) was used to quantify the streamlines outgoing from the olfactory structures and to quantify changes in FA, MD, and RD within olfactory structures. These brain changes were correlated with olfactory function measured as TDI (Threshold, Discrimination, Identification) scores in patients and compared to our own reference group of 30 healthy volunteers., Results: Central olfactory structures in the MNI (Montreal Neurological Institute) data volume comprise 4808 voxels (4808 mm(3)). TFCE (Threshold-free cluster enhancement) and cluster analysis of patients identified a total of 127 voxels in one cluster with a significantly decreased FA (p<0.05) and none for MD and RD within olfactory structures compared to healthy controls. The correlation with the age-normalised Identification subscore of the TDI score increased the significant number of voxels with decreased FA to 208 voxels, with increased MD to 370 and with increased RD 364 voxels at the same region., Conclusion: The decrease in FA and increase of MD and RD correlate with the degree of identification impairment of olfactory function in MS patients and clusters of abnormalities were identified on a MNI data volume., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Science has a critical role to play in guiding more sustainable development trajectories. Here, we present the Sustainable Amazon Network (Rede Amazônia Sustentável, RAS): a multidisciplinary research initiative involving more than 30 partner organizations working to assess both social and ecological dimensions of land-use sustainability in eastern Brazilian Amazonia. The research approach adopted by RAS offers three advantages for addressing land-use sustainability problems: (i) the collection of synchronized and co-located ecological and socioeconomic data across broad gradients of past and present human use; (ii) a nested sampling design to aid comparison of ecological and socioeconomic conditions associated with different land uses across local, landscape and regional scales; and (iii) a strong engagement with a wide variety of actors and non-research institutions. Here, we elaborate on these key features, and identify the ways in which RAS can help in highlighting those problems in most urgent need of attention, and in guiding improvements in land-use sustainability in Amazonia and elsewhere in the tropics. We also discuss some of the practical lessons, limitations and realities faced during the development of the RAS initiative so far.

Background: Previous research has shown that multiple sclerosis (MS) patients can develop olfactory disturbances., Objective: The purpose of our study was to investigate how olfactory function in MS patients correlates with cerebral magnetic resonance imaging (MRI) including diffusion tensor imaging (DTI)., Methods: Olfactory performance was tested in 30 MS patients and 30 controls to determine odour threshold (T), odour discrimination (D), and odour identification (I) summarised in the TDI score. The lesion load (number and total volume of lesions) was measured on proton-density (PD)- and T2-weighted images of the olfactory brain and the total brain. Fractional anisotropy (FA) of the lesions and the surrounding normal-appearing brain tissue (NABT) was quantified using DTI., Results: The median FA of white matter lesions was 0.29 and was on average 11.1% lower than in the surrounding NABT. The normalised TDI score and the normalised I subscore were significantly poorer in the MS group compared to controls (p<0.0001), while the T and D subscores were similar in both groups. The median FA of lesions in the olfactory brain correlated inversely with the decreased I subscore (p=0.001). There was also a strong correlation between the TDI score and the Expanded Disability Status Scale (EDSS) (p=0.001)., Conclusion: A strong inverse relationship between decreased odour identification ability of MS patients and FA values in the olfactory brain indicates that the reduction in I is more strongly affected by lesions in areas with high FA values, i.e., with an increased amount of affected white matter tracts., (Copyright © 2012 Elsevier B.V. All rights reserved.)