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Background: Infective endocarditis (IE) has increased in rural states such as West Virginia (WV) with high injection drug use. IE is medically managed with antimicrobial treatment alone or combined with surgical treatment. This study aimed to characterize the predictors associated with surgical treatment and rates of inpatient mortality and readmission among IE patients in WV's rural centers., Methods: This retrospective review of electronic health records includes all adults hospitalized for IE at major rural tertiary cardiovascular centers in WV during 2014-2018. Descriptive statistics were presented on demographics, history of injection drug use, clinical characteristics, and hospital utilization by surgery status, and multivariable logistic regression examined the association of surgery with key predictor variables, generating odds ratios (OR)., Results: Of the 780 patients with IE, 38% had surgery, with a 26-fold increase in patients undergoing surgery between 2014-2018. Comparing surgery and non-surgery patients revealed significant differences. Surgery patients were significantly younger (median age 35.6 vs. 40.5 years; p<0.001); had higher rates of drug use history (80% vs. 65%; p<0.001), psychiatric disorders (57% vs. 31%; p<0.001), and readmissions (18% vs.12%; p = 0.015). Surgery patients had lower rates of discharge against medical advice (11% vs.17%; p = 0.028) and in-hospital mortality (5% vs.12%; p<0.001). In the multivariable logistic regression, surgery was associated with injection drug use (OR: 1.9; 95% CI:1.09-3. 3), indications for surgery (OR: 1.68; 95% CI:1.48-1.91), left-sided IE (OR: 2.14; 95%CI:1.43-3.19) and later years (OR:3.75; 95%CI:2.5-5.72)., Conclusion: This study characterizes the predictors associated with surgical treatment and rates of inpatient mortality and readmission among IE patients across rural WV. The decision to perform cardiac surgery on IE patients is complex. Results with increased injection drug use-associated IE emphasize the importance of comprehensive care by a multidisciplinary team for optimal management of patients with IE., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

71-year-old male with epidural spinal lipomatosis and spondylolisthesis. Conservative treatment failed, and a spinal fusion and laminectomy were performed. Postoperatively, the patient reported a reduction in pain; however, the pain recurred soon after surgery. After losing 53 pounds with medical management, the patient reported a complete absence of pain. Epidural spinal lipomatosis is a rare condition characterized by the deposition and hypertrophy of adipose tissue in the spinal canal, sometimes resulting in stenosis or compression of the dural sac and nerve roots ( Glob Spine J . 2018;9:658). Although several factors are considered to precipitate the disease, steroid use ( J Am Acad Dermatol . 2017;76:1) and obesity ( Neurosurg Focus . 2004;16:1) are considered among the most prevalent, with obesity controversially being listed under "idiopathic" causes occasionally ( Glob Spine J . 2018;9:658). Weight reduction and decreased steroid use are first-line treatments for this disorder, and usually surgery is considered only when conservative treatment is ineffective ( Glob Spine J . 2018;9:658). To describe a case of treating spinal lipomatosis within an evidence-based multidisciplinary medical weight management clinic., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Background: Stigma is understood to be intersectional, meaning multiple characteristics can be stigmatizing, and they may be both overlapping and coconstitutive. Chronic pain and overweight are common complaints in the spinal surgery clinic. Since being overweight may relate to back pain in a complex fashion, we sought to understand if there is a moderating effect between weight bias and pain stigma., Methods: This study involves a survey-based, quantitative, cross-sectional, observational design using previously validated measures and demographic and clinical information. There were 192 participants. Statistical calculations were done with statistical package for the social sciences., Results: Pain stigma was not significantly correlated with BMI (body mass index), and weight bias was not significantly correlated with back pain. There was a strong positive correlation between weight bias and pain stigma. There was a strong positive correlation between weight bias and BMI when pain stigma was also high., Conclusions: Given the relationship between weight stigma and pain, the intersection of weight and pain stigma is important because it indicates the vulnerability of patients with higher BMI to other forms of stigma, such as stigma for their pain complaints. Clinicians should be mindful of expressing pain stigma more significantly amongst patients with higher BMI., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Chronic otitis media (COM) is the long-term infection and inflammation of the middle ears typically caused by upper respiratory tract pathogens that are able to ascend the Eustachian tube. Our understanding of contributing factors is limited because human otopathogens cannot naturally colonize or persist in the middle ears of mice. We recently described a natural COM in mice caused by Bordetella pseudohinzii and proposed this as an experimental system to study bacterial mechanisms of immune evasion that allow persistent infection of the middle ear. Here we describe a novel pertussis toxin (PTx)-like factor unique to B. pseudohinzii , apparently acquired horizontally, that is associated with its particularly efficient persistence and pathogenesis. The catalytic subunit of this toxin, PsxA, has conserved catalytic sites and substantial predicted structural homology to pertussis toxin catalytic subunit PtxA. Deletion of the gene predicted to encode the catalytic subunit, psxA , resulted in a significant decrease in persistence in the middle ears. The defect was not observed in mice lacking T cells, indicating that PsxA is necessary for persistence only when T cells are present. These results demonstrate the role of a novel putative toxin in the persistence of B. pseudohinzii and its generation of COM. This PsxA-mediated immune evasion strategy may similarly be utilized by human otopathogens, via other PTx-like toxins or alternative mechanisms to disrupt critical T cell functions necessary to clear bacteria from the middle ear. This work demonstrates that this experimental system can allow for the detailed study of general strategies and specific mechanisms that otopathogens use to evade host immune responses to persist in the middle ear to cause COM., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ma, Sedney, Su, Dewan, Linz and Harvill.)

Acute otitis media (AOM) is commonly caused by bacterial pathobionts of the nasopharynx that ascend the Eustachian tube to cause disease in the middle ears. To model and study the various complexities of AOM, common human otopathogens are injected directly into the middle ear bullae of rodents or are delivered with viral co-infections which contribute to the access to the middle ears in complex and partially understood ways. Here, we present the novel observation that Bordetella bronchiseptica , a well-characterized respiratory commensal/pathogen of mice, also efficiently ascends their Eustachian tubes to colonize their middle ears, providing a flexible mouse model to study naturally occurring AOM. Mice lacking T and/or B cells failed to resolve infections, highlighting the cooperative role of both in clearing middle ear infection. Adoptively transferred antibodies provided complete protection to the lungs but only partially protected the middle ears, highlighting the differences between respiratory and otoimmunology. We present this as a novel experimental system that can capitalize on the strengths of the mouse model to dissect the molecular mechanisms involved in the generation and function of immunity within the middle ear., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Dewan, Sedney, Caulfield, Su, Ma, Blas-Machado and Harvill.)

Background: Obesity is a leading public health concern in the United States. One promising method for enhancing patient activation to engage in health promoting behaviors is with technology in the primary care setting. The primary purpose of this study was to test the usability of a patient activation tool, called mWRAPPED, for weight management during primary care wait times., Methods: A two-cycle approach to usability testing was followed by a pragmatic usability study in the primary care setting. The application was subsequently revised based on patient feedback. A convenience sample of patients completed usability testing in the clinical setting. Patients completed the System Usability Scale throughout all testing phases., Results: First cycle patients provided an average score of 76.5 on the System Usability Scale. After revising mWRAPPED, the average patient System Usability Scale score increased to 80.5. mWRAPPED received an average System Usability Scale score of 77.9 when tested in the clinical setting. mWRAPPED demonstrated initial usability for primary care patients in an academic outpatient family medicine clinical setting., Conclusions: Results of the current study will help to support the use of this application in future studies as a novel approach to delivering guideline-based weight management information to patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/mhealth-20-119). The authors have no conflicts of interest to declare., (2021 mHealth. All rights reserved.)

Objective  Clinicians are beginning to evaluate the effects that Internet use has on patients. The aim of this study is to provide descriptive information on patients' use of the Internet in regard to their spinal pain. Additionally, this study aims to examine the patient's type of Internet usage (information vs. support) and its relationship to pain-related distress. Materials and Methods  This quantitative-descriptive, survey-based, correlational, cross-sectional design surveyed 143 spinal surgery patients from the Appalachian region. Participants were administered a demographic questionnaire, the pain catastrophizing scale, and an Internet Use and Spine Patients Questionnaire. Descriptive information on patient Internet use was collected through a retrospective recall of the participants' Internet use and was analyzed utilizing a frequency distribution. A Pearson ( r ) correlation was conducted to determine the relationship between Internet use and the severity of pain catastrophizing. Results  Spinal surgery patients more frequently use the Internet for information than for support. For the individuals who do utilize the Internet for information, most are finding this tool to be somewhat helpful. For spinal patients who do use the Internet for support, there was a positively correlated relationship with magnification, helplessness, and overall pain catastrophizing. Conclusion  Patients who present for spinal surgery are generally using the Internet to gain information on their diagnoses. Pain catastrophizing was elevated in relation to Internet use for support. Limitations and future directions are discussed., Competing Interests: Conflict of Interest None declared., (Association for Helping Neurosurgical Sick People. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objectives: Prone positioning has been shown to be a beneficial adjunctive supportive measure for patients who develop acute respiratory distress syndrome. Studies have excluded patients with reduced intracranial compliance, whereby patients with concomitant neurologic diagnoses and acute respiratory distress syndrome have no defined treatment algorithm or recommendations for management. In this study, we aim to determine the safety and feasibility of prone positioning in the neurologically ill patients., Design and Setting: A systematic review of the literature, performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses 2009 guidelines, yielded 10 articles for analysis. Using consensus from these articles, in combination with review of multi-institutional proning protocols for patients with nonneurologic conditions, a proning protocol for patients with intracranial pathology and concomitant acute respiratory distress syndrome was developed., Measurements and Main Results: Among 10 studies included in the final analysis, we found that prone positioning is safe and feasible in the neurologically ill patients with acute respiratory distress syndrome. Increased intracranial pressure and compromised cerebral perfusion pressure may occur with prone positioning. We propose a prone positioning protocol for the neurologically ill patients who require frequent neurologic examinations and intracranial monitoring., Conclusions: Although elevations in intracranial pressure and reductions in cerebral perfusion pressure do occur during proning, they may not occur to a degree that would warrant exclusion of prone ventilation as a treatment modality for patients with acute respiratory distress syndrome and concomitant neurologic diagnoses. In cases where intracranial pressure, cerebral perfusion pressure, and brain tissue oxygenation can be monitored, prone position ventilation should be considered a safe and viable therapy., Competing Interests: Dr. Alkhachroum received funding from National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under the Miami Clinical and Translational Science Institute KL2 Career Development Award UL1TR002736. Dr. Sedney’s institution received funding from NIH/National Institute on Aging, and she received funding from Arbeitsgemeinschaft für Osteosynthesefragen Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: Management of AF requires patient engagement in disease management which requires adequate knowledge about AF., Objective: To identify the patient characteristics associated with low AF knowledge among older adults with AF., Methods: The SAGE-AF cohort enrolled adults aged ≥65 diagnosed with AF in 2016-2018. Patient characteristics associated with low AF knowledge (<6/8 JAKQ items correct) were examined using multivariable adjusted logistic regression models., Results: Participants (N = 950) were on average 74 years old (SD: 6.7), 50 % female, and 87 % non-Hispanic white. The average JAKQ score was 68.7 (SD: 17.1), and 78 % had low AF knowledge. Participants aged ≥ 75 (OR: 1.55, 95 % CI: 1.03, 2.33), without a college degree (OR: 0.46, 95 % CI: 0.32, 0.65), cognitively impaired (OR: 1.72, 95 % CI: 1.15, 2.58), with a history of anxiety (OR: 1.76, 95 % CI: 1.09, 2.83), myocardial infarction (OR: 1.82, 95 % CI: 1.08, 3.07), and heart failure (OR: 1.84, 95 % CI: 1.16, 2.91) were more likely to have low AF knowledge., Practice Implications: Characteristics available in the electronic medical record may identify patients at risk for low AF knowledge. Formal assessment of AF knowledge may identify areas of weakness and allow for targeted education., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction Increasing demands for healthcare manpower has necessitated the utilization of advanced practice providers (APPs). The effect of APPs in primary care has been well-characterized but is less studied in surgical subspecialties. The objective of this study is to assess the patient acceptability of APPs in an outpatient neurosurgery setting. Methods We conducted a prospective, survey-based study among 78 adult patients in the neurosurgical outpatient clinic. The survey consisted of 10 questions assessing the hypothetical acceptability of care provided by neurosurgeons and APPs. These were compared as pre-specified dyads, with patients blinded to dyad composition. The data were analyzed with Chi-square tests. Results Patients preferred to see their neurosurgeon for their first clinic visit even with a longer lag time (29% acceptability difference, p = 0.012). Patients also preferred to see the neurosurgeon for their first postoperative visit (20% difference, p = 0.009). For all visits, patients preferred to see an APP if the clinic visit would be on time, rather than see the surgeon with a significant delay (30% difference, p = 0.0002). If their visit was scheduled with an APP, patients preferred that the neurosurgeon review their treatment plan before they left the clinic (15% difference, p = 0.04). Overall, seeing an APP was acceptable if patients were informed ahead of time (37% difference, p < 0.0001). Conclusions Team-based care utilizing APPs is acceptable to patients. Patients had strong preferences for seeing their surgeon for the first neurosurgical clinic visit and first post-operative visit. Patients were satisfied with seeing an APP if they could be seen more expeditiously. Patients also preferred to know ahead of time if they were going to see an APP., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Cheyuo et al.)

Objective  Elective lumbar and cervical operations are becoming more common in the United States. Additionally, there is a movement in the literature and clinical practice to discover short versions of longer measures as a way to anticipate an outcome. This study aims to provide neurosurgeons in practice with a three-item questionnaire that can guide referrals to psychological services presurgery. Ultimately, results could lead to an improvement in health-related quality of life (HRQoL) postspinal surgery. Methods  This quantitative-descriptive, survey-based design with a retrospective chart review component followed 47 patients at baseline ( N = 47), 3 months ( N = 20), 6 months ( N = 31), and 1 year ( N = 19). A single item from the Coping Strategies Questionnaire, the Survey of Pain Attitudes, and the Tampa Scale of Kinesiophobia were utilized in the three-item questionnaire as a baseline measure. Patient-Reported Outcomes Measurement Information System Global Health measured HRQoL outcome at all time points. A linear regression model was conducted to predict mental health QoL postspinal surgery. Results  This measure can predict mental health QoL outcomes up to 3-month postsurgery. Six-month and 1-year follow-ups are statistically inconclusive. Conclusion  Individuals who are undergoing spinal surgery show lower mental health QoL outcome at baseline and 3-month postsurgery when responses on a three-item questionnaire are elevated. Limitations and future directions are discussed., Competing Interests: Conflict of Interest None declared.

Objective: The notion of therapeutic nihilism may lead to early removal of care based upon perceived poor prognosis. The goal of this study was to examine if differences for nihilism perspectives exist between professions and within professions at the different levels of experience and exposure to neurological conditions., Method: Survey methods was used to assess perception of care futility and therapeutic nihilism using six case-based scenarios followed by five questions regarding practitioner care choices and perspective. Participants were student and professional occupational and physical therapists, nurses, and doctors (n = 110). Thematic analysis was completed to determine influences on patient care., Results: Six themes (quality of life, provider experience, prognosis/treatability, medical details, patient's age, and family/patient wishes) emerged that influenced treatment decisions across all participants. All provider groups reported prognosis and treatability as their number one factor for treatment decisions, then therapists mentioned QOL most, nurses cited age, and doctors said medical details. Differences between students and professionals were also apparent., Discussion: The perceived ability of the patient to recover (prognosis/treatability) with medical care was the most commonly cited reason for aggressive measures, with quality of life, medical details, and patient age also representing strong themes across disciplines and level of training., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: To compare mobile health (mHealth) usage by residents of West Virginia with national estimates., Methods: Pew Research Center data from its Internet and American Life Project were accessed for secondary data analysis. These data, available to the public, are a probability sample of Internet use in the United States, differences in use based on selected variables (eg, education, household income), and how usage affects the lives of Americans. Using SAS software, diagnostics were performed on the data, revealing that the variables of interest were prepared and represented without any need for information. Data were used as is, with categorical and continuous characteristics and stipulations being provided in accompanying documents from the Pew Research Center., Results: The national sample consisted of 509 men and 557 women with an average age of 51.02 years (standard deviation 17.04). The 30 West Virginia residents included 19 women and 11 men (mean for age 48.10, standard deviation 15.30). When controlling for socioeconomic and demographics factors, the odds of a West Virginia resident using an mHealth device were 82% less than the rest of the country, a statistically significant association. Women in West Virginia were 52% more likely to access mHealth information than men, and an increase in age corresponded with increased mHealth usage., Conclusions: The lack of mHealth use by residents in West Virginia represents an opportunity for clinicians and scientists. The high rates of preventable diseases in the region could be more effectively managed with greater use of these technologies.

Background: In low- and middle-income countries (LMICs), 11.8% of the need for neurosurgical care is met. Delays in seeking and receiving care may further exacerbate this situation. Objective analysis of delay and its consequences is contingent on reference to established resource-appropriate acceptable timeframes. This study sought to 1) establish an estimate of the landscape of care provided in LMICs and 2) explore reasonable timeframes for various stages of patient-health care interaction., Methods: Consensus input from neurosurgeons in select LMICs was collected; 1 high-income country was included for comparison. In phase 1, participants were asked to select neurosurgical procedures performed at their centers. In phase 2, based on procedures shared among all LMICs, representative case scenarios were generated and participants provided input on acceptable timeframes for each stage of patient-health care interaction: 1) presentation to health services, 2) diagnosis by primary care physician, 3) referral to neurosurgical specialist care, and 4) definitive neurosurgical management., Results: Twenty neurosurgeons across 18 centers were identified; 12 participated in phase 1 and 7 in phase 2. The range of procedures offered was broad, similar in scope to high-income countries, and included pediatric and adult neurosurgery, trauma, degenerative spine, and hemorrhagic stroke. Acceptable timeframes had wide ranges in certain cases; however, the overall trend showed agreement between the participants., Conclusions: This exploratory analysis identified reasonable timeframes for the provision of neurosurgical care in LMICs. If validated, these data can be used to more objectively assess the prevalence of delay in neurosurgical care in individual LMICs, along with its consequences., (Copyright © 2018 Elsevier Inc. All rights reserved.)

To date, this is the first reported case of the surgical management of a holocord epidural abscess done through level-skipping laminectomies. It is also the first reported case of these laminectomies being performed via an alternating side unilateral approach for this condition. A 51-year-old patient presenting with progressive lower extremity weakness secondary to a spinal epidural abscess extending from C4 to S1. A minimally disruptive method of relieving the spinal cord compression via evacuation of the abscess was employed successfully. This report demonstrates the efficacy of level skipping laminectomies via a unilateral approach for holocord epidural abscesses (extending 20 vertebral levels). Performing the laminectomies via a unilateral approach as well as alternating the side of the approach minimized iatrogenic instability risk. Both strategies were designed to minimize incision size, tissue disruption, and the amount of muscular weakness/imbalance postoperatively.

Objective: To explore the perspectives of Ethiopian and international neurosurgeons on the development of a sustainable academic neurosurgery teaching unit in Addis Ababa, Ethiopia., Methods: A qualitative case study methodology was employed., Results: Ethiopian and international surgeons describe a rewarding cross-cultural experience. Areas in need of improvement include communication, educational infrastructure, and structured morbidity and mortality discussions. Data collection that aims to understand better the burden of neurosurgical disease in Ethiopia along with rapidly expanding Ethiopian government initiatives to improve the health care system will lead to improved patient care., Conclusions: Genuine partnerships between surgeons who have trained and worked in well-developed neurosurgical centers and those that are working within the confines of limited resources have the mutual desire to improve neurosurgical care. Understanding each other's perspective is an important aspect of program development., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective and Importance: Fibrous dysplasia is a benign skeletal condition which can involve the craniofacial skeleton. Surgery is indicated for correction of deformity and neurovascular decompression. Traditional surgery involves harvesting remote bone or calvarial grafts, requiring prolonged, multisite procedures. Custom implants may eliminate the need for bone harvesting, but usually require staged procedures with interim bony defects. We report the use of preoperative cranial modeling and implant design, allowing for a single reconstructive procedure., Clinical Presentation: A 32-year-old woman with McCune-Albright syndrome was referred to Neurosurgery and Ophthalmology for right facial pain, deformity, and eye pressure. Examination revealed a 6-mm right eye proptosis and decreased sensation and severe pain in the right V2 distribution. Imaging demonstrated extensive fibrous dysplasia, with right orbital mass effect and nerve compression., Intervention: A single procedure was planned to remove and replace the involved bone. High-resolution CT was used to create a scale model of the patient's cranium. The planned resection was performed on the model, allowing for preoperative custom implant design. We then performed single-stage resection and reconstruction. The right superior and lateral orbital rims, portions of the left superior and medial orbital rims, and the nasion were resected. The custom implant was contoured to fit and remaining small defects were filled with Fast Set Norian. No complications occurred. At follow-up, the patient reported pain and pressure relief, and examination showed resolution of proptosis, improved sensation, and excellent cosmesis., Conclusion: Preoperative cranial modeling and implant design allows for a shorter, one-step resection and reconstruction procedure without compromising structural or cosmetic outcome.