Endovascular thrombectomy for posterior cerebral artery strokes in the national inpatient sample (EaT PeCANpIeS) study

BACKGROUND

Posterior cerebral arteries with acute ischemic strokes (PCA-AISs) comprise around 2% of all acute ischemic strokes and may result in significant long-term deficits. Current guidance regarding endovascular thrombectomy (EVT) for PCA-AIS is insufficient as no published randomized trials exist.

METHODS

An analysis of the National Inpatient Sample database compared medical management versus EVT for PCA-AIS. Propensity score matching was applied to adjust for nonrandomization.

RESULTS

The study included 19,655 patients. Before matching, the EVT cohort had significantly higher National Institutes of Health Stroke Scale (NIHSS) (10.21 vs. 4.67, p < 0.001), had lower rates of favorable functional outcomes, functional independence, and higher rates of intracranial hemorrhage (ICH) and inpatient mortality. After matching, no differences in functional outcomes were identified, but revealed a higher proportion of ICH in the EVT group (17.45% vs. 8.98%, p < 0.001). However, NIHSS subgroup analysis identified improved functional outcomes associated with the EVT group who presented with an NIHSS between 10 and 19 both in terms of rates of favorable functional outcomes (35.56% vs. 12.09%, p < 0.001) and rates of functional independence (26.67% vs. 9.34%, p < 0.01). On further investigation, the clinical benefit, in the NIHSS 10-19 subgroup, was driven by patients receiving EVT in combination with intravenous thrombolysis (IVT).

CONCLUSIONS

This analysis shows that current national practices utilize EVT for more severe PCA strokes. Clinical benefit was only detected in patients with moderate stroke severity (NIHSS 10-19) who were treated with combined EVT and IVT. Further work is needed to investigate the features of PCA-AIS that might benefit from EVT the most.

Peritumoral edema in meningiomas: pathophysiology, predictors, and principles for treatment

Meningiomas is a tumor of the meninges and is among the most common intracranial neoplasms in adults, accounting for over a third of all primary brain tumors in the United States. Meningiomas can be associated with peritumoral brain edema (PTBE) which if not managed appropriately can lead to poor clinical outcomes. In this review, we summarize the relevant pathophysiology, predictors, and principles for treatment of PTBE. The results of various case-reports and case-series have found that meningioma-associated PTBE have patterns in age, tumor size, and hormone receptor positivity. Our study describes how increased age, increased tumor size, tumor location in the middle fossa, and positive expression of hormone receptors, VEGF, and MMP-9 can all be predictors for worse clinical outcomes. We also characterize treatment options for PTBE such as glucocorticoids and VEGF inhibitors along with the ongoing clinical trials attempting to alleviate PTBE in meningioma cases. The trends summarized in this review can be used to better predict the behavior of meningioma-associated PTBE and establish prognosis models to identify at risk patients.

Hounsfield Unit as a Predictor of Adjacent-Level Disease in Lumbar Interbody Fusion Surgery

BACKGROUND

Bone density has been associated with a successful fusion rate in spine surgery. Hounsfield units (HUs) have more recently been evaluated as an indirect representation of bone density. Low preoperative HUs may be an early indicator of global disease and chronic process and, therefore, indicative of the need for future reoperation.

OBJECTIVE

To assess preoperative HUs and their association with future adjacent segment disease requiring surgical intervention through retrospective study.

METHODS

Patients who underwent lumbar interbody fusion at a single institution between 2007 and 2016 were retrospectively reviewed. Hounsfield unit values were measured from preoperative computed tomography (CT) using sagittal images, encircling cancellous portion of the vertebral body. Patient charts were reviewed for follow-up data and adjacent-level disease development.

RESULTS

A total of 793 patients (age: 56.1 ± 13.7 years, 54.4% female) were included in this study. Twenty-two patients required surgical intervention for adjacent segment disease. Patients who underwent lumbar interbody fusion and did not subsequently require surgical intervention for adjacent-level disease were found to have a higher mean preoperative HU than patients who did require reoperation (180.7 ± 70.0 vs 148.4 ± 8.1, P = .032). Preoperative CT HU was a significant independent predictor for the requirement of adjacent-level surgery after spinal arthrodesis (odds ratio = 0.891 [0.883-0.899], P = .029).

CONCLUSION

Patients who underwent lumbar interbody fusion that did not require reoperation for adjacent-level degeneration were found to have a higher mean preoperative HU than patients who did require surgical intervention. Lower preoperative CT HU was a significant independent predictor for the requirement of adjacent-level surgery after spinal arthrodesis.

Dysregulation of Biomarkers of Hemostatic Activation and Inflammatory Processes are Associated with Adverse Outcomes in Pulmonary Embolism

Introduction

The pathophysiology of pulmonary embolism (PE) represents complex, multifactorial processes involving blood cells, vascular endothelium, and the activation of inflammatory pathways. Platelet (P), endothelial (E), and leukocyte (L)-selectin molecules may play an important role in PE pathophysiology. We aimed to profile the biomarkers of inflammation, including selectins in PE patients, and compare them to healthy individuals.

Materials and methods

100 acute PE patients and 50 controls were included in this case control study. ELISA methods were used to quantify levels of selectins, inflammatory, and hemostatic biomarkers.

Results

In PE patients, levels of selectin molecules as compared to controls convey increased P-selectin levels (95 ng/mL vs 40 ng/mL, p < .0001) and decreased L-selectin levels (1468 ng/mL vs 1934 ng/mL, p < .0001). Significant correlations were found between selectins and Plasminogen Activating Inhibitor-1 (PAI-1), Tumor Necrosis Factor-a (TNFa), and D-dimer. Fold change between selectins and controls is compared to other biomarkers, illustrating degrees of change comparable to TNFa, alpha-2-antiplasmin, and microparticles. L-selectin levels are inversely associated with all-cause-mortality in PE patients, (p = .040).

Conclusion

These studies suggest that various thrombo-inflammatory biomarkers are elevated in PE patients. Furthermore, L-selectin levels are inversely associated with mortality outcomes.

Outcomes of anterior vs. posterior approach to single-level lumbar spinal fusion with interbody device: An analysis of the nationwide inpatient sample

BACKGROUND

Interbody devices have revolutionized lumbar spinal fusion surgery by improving mechanical stability and maximizing fusion potential. Several approaches for interbody fusion exist with two of the most common being anterior lumbar interbody fusion (ALIF) and posterior lumbar interbody fusion (PLIF). This study aims to compare patient data, hospital outcomes, and post-operative complications between an anterior vs. posterior approach to lumbar interbody fusion.

METHODS

This retrospective cohort study utilized the Nationwide Inpatient Sample (NIS) and International Classification of Diseases, 10th edition (ICD10) codes to identify patients (18 +) from 2016 to 2018 who underwent lumbar interbody fusion under an anterior or posterior approach. Patients missing identifiers were excluded from this study. Patients were further investigated by demographic data and the presence of comorbidities. Hospital outcome data was investigated by length of stay (LOS), total hospital charges, mortality, and post-operative complications.

RESULTS

373,585 patients were included in this study. 257,975 (69%) underwent fusion via a posterior approach, and 115,610 (31%) via an anterior approach. Patients undergoing posterior approach were found to have a greater number of comorbidities than anterior (3.5 vs. 2, respectively, p = <0.001). The posterior approach was associated with decreased LOS (3.59 vs 4.19 days, p = <0.0001) and decreased total hospital charges ($141,700 vs $211,015, p = <0.0001). A posterior approach was found to have lower rates of post-operative complications. For the anterior approach cohort, tobacco dependence (OR=1.31 [1.20-1.42, p = <0.001], diabetes (OR=2.41 [2.33-2.49, p = <0.001], and osteoporosis (OR=1.42 [1.30-1.54, p = <0.001] were found to be significant independent predictors of post-operative pseudoarthrosis. Obesity (OR=1.28 [1.14-1.42, p = <0.001], tobacco dependence (OR=1.48 [1.40-1.56, p = <0.001], diabetes (OR=2.21 [2.10-2.32, p = <0.001], congestive heart failure (OR=1.20 [1.01-1.39, p = 0.04], and osteoporosis (OR=1.65 [1.55-1.75, p = <0.001], were found to be independent predictors of post-operative pseudoarthrosis in the posterior cohort.

CONCLUSIONS

Patients who underwent the anterior approach suffered from increased hospital charges, length of stay, and increased risk of post-operative complications including mortality, wound dehiscence, hematoma/seroma, and pseudoarthrosis. Comorbid disease plays a significant role in the outcome of successful fusion with variable effect depending on the surgical approach. Increasing due diligence in patient selection should be considered when choosing an approach in pre-operative planning.

Sacroiliac Joint and Pelvic Dysfunction Due to Symphysiolysis in Postpartum Women

Pregnancy-related pain in the sacroiliac joint (SIJ), lumbosacral region, pubic symphysis, or in any combination of these joints has been coined as pelvic girdle pain (PGP) and has been estimated to affect almost half of all pregnant women. SIJ dysfunction in pregnancy is due to multiple biomechanical mechanisms, such as increased weight, change in posture, increased abdominal and intrauterine pressure, and laxity of the spine and pelvic structures. Moreover, when compared to men, women have increased SIJ mobility due to increased pubic angle and decreased SIJ curvature. These differences may assist in parturition where hormones, such as relaxin and estrogen, cause symphysiolysis. A retrospective review of the literature was conducted in the PubMed database using the search term “pregnancy-related sacroiliac joint pain.” All peer-reviewed studies were included. Around 8%-10% of women with PGP continue to have pain for one to two years postpartum. Patients that were treated with SIJ fusion show statistically significant improvement in pain scores when compared to patients that had non-operative treatment. Although we have a number of studies following patients after sacroiliac (SI) joint fusion for pelvic pain with SI joint dysfunction, further research is needed to study sacroiliac fusion for SI joint dysfunction in postpartum women to better tailor and optimize surgical outcomes for this patient population.

National Trends for Peripheral Artery Disease and End Stage Renal Disease From the National Inpatient Sample Database

Peripheral artery disease (PAD), and subsequent chronic limb-threatening ischemia (CLTI), are frequently encountered among patients with end-stage renal disease (ESRD). Their coexistence is less favorable in comparison to patients with ESRD alone. We sought to investigate trends, comorbidities, determinants for cost, and prognostic outcomes in patients with concomitant ESRD and PAD. A retrospective analysis was performed using data from the National Inpatient Sample database from the years 2005-2014. ICD-9 codes were used to identify patients with diagnoses of PAD, CLTI, and ESRD. Pearson’s Chi-square, T-test, ANOVA, and multivariate binary logistic regression were used in this analysis. 7,214,843 patients with ESRD were identified. Of these, 123,499 patients were diagnosed with PAD and 102,447 with CLTI. Compared to ESRD alone, mortality rates increased with PAD and CLTI (5.7% vs. 13.9% vs. 15.9%, P < 0.001). Length of stay in days (7.3 vs. 10.2 vs. 11.1, P < 0.001) and in-hospital costs (59,872 vs. 85,866 vs. 89,016, P < 0.001) were higher with PAD and CLTI, respectively. CLTI demonstrated the highest independent predictor of mortality [OR = 6.93 (6.43-7.46), P < 0.001]. A decreasing trend in the rate of PAD (2005: 1.9% vs. 2014: 1.4%, P < 0.001) and CLTI (2005: 1.6% vs. 2014: 1.1%, P < 0.001) was noted. The presence of coexisting PAD, and furthermore CLTI, in patients with ESRD significantly raised in-hospital mortality, cost, and length of stay. A negative trend in rates of PAD and CLTI were observed. Proactive identification of this high-risk population may lead to accurate diagnosis and tailored therapeutic strategies.

Effect of comorbidities on ischemic stroke mortality: An analysis of the National Inpatient Sample (NIS) Database

Background

Stroke risk has been attributed to many pathological and behavioral conditions. Various modifiable and non-modifiable risk factors have been recognized and found consistent throughout epidemiological studies. Herein, we investigate the effect of comorbidities seen with patient's suffering from ischemic stroke and its effect on in-hospital mortality.

Methods

We identified patients >18 year old in the National Inpatient Sample database with diseases of interest utilizing the tenth International Classification of Disease 10 diagnostic codes from the years 2016 to 2018. Interval data were analyzed using one-way ANOVA. Post hoc analysis was performed using Bonferroni correction methods. To determine independent predictors of in-hospital mortality, odds ratios were calculated using binary logistic regression for each comorbidity. Descriptive and numerical statistics, imputation, and logistic regression were calculated using SPSS software version 25.

Results

Patients hospitalized with ischemic stroke were found to have the following comorbidities: atrial fibrillation (7.5%), carotid artery stenosis (1.1%), diabetes mellitus type 2 (11.4%), congestive heart failure (CHF) (7.5%), essential hypertension (21.2%), and ischemic heart disease (IHD) (2.3%). In-hospital mortality rates were higher in patients hospitalized with ischemic stroke and concomitant IHD (28.2%, P < 0.001). Hospital length of stay was longest in patients with concomitant CHF (5.96 days, P < 0.001). Similarly, patients with CHF accrued the greatest in-hospital costs (69,174 USD, P < 0.001).

Conclusion

Patients hospitalized from ischemic stroke suffered from the coexistence of other comorbidities. Of the comorbidities studied, IHD was identified as having the most significant impact on in-hospital mortality.

Nonmissile penetrating spinal injuries: Mechanisms, expectations, and management

Background:

Nonmissile penetrating spinal injury (NMPSI) is an uncommon form of traumatic injury to the spine. Here, we present a comprehensive and contemporary literature review that provides insight into NMPSI-type injuries, their mechanisms, clinical practice, management, and expectations.

Methods:

An extensive review of the published literature was conducted in PubMed, OVID Medline, and EMBASE journals for studies of nonmissile penetrating spine injuries. Terms for search included NMPSI and nonmissile penetrating spinal cord injury. No date restrictions were used.

Results:

The search yielded only 17 related articles. Cross-checking of articles was conducted to exclude duplicate articles. The 17 articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic.

Conclusion:

The mechanism of injury in NMPSI occurs in two different stages. Immediate injury is caused by direct damage to the neurological structures. The delayed injury response is caused by damage to the spinal vasculature and activated immune response pathways. Computed tomography (CT) angiograms or formal diagnostic angiograms are indicated to identify vascular injury or development of pseudoaneurysm and can be performed both preoperatively and postoperatively. Surgically, decompressive procedures include laminectomies and hemilaminectomies. Dural exploration may be indicated if a cerebrospinal fluid leak with fistula develops from dural puncture. Further research and technologies are being developed to provide patients who have suffered NMPSI with more resources for a better quality of life.

Comparison of low- and ultralow-dose computed tomography protocols for quantitative lung and airway assessment

PURPOSE

Quantitative computed tomography (CT) measures are increasingly being developed and used to characterize lung disease. With recent advances in CT technologies, we sought to evaluate the quantitative accuracy of lung imaging at low- and ultralow-radiation doses with the use of iterative reconstruction (IR), tube current modulation (TCM), and spectral shaping.

METHODS

We investigated the effect of five independent CT protocols reconstructed with IR on quantitative airway measures and global lung measures using an in vivo large animal model as a human subject surrogate. A control protocol was chosen (NIH-SPIROMICS + TCM) and five independent protocols investigating TCM, low- and ultralow-radiation dose, and spectral shaping. For all scans, quantitative global parenchymal measurements (mean, median and standard deviation of the parenchymal HU, along with measures of emphysema) and global airway measurements (number of segmented airways and pi10) were generated. In addition, selected individual airway measurements (minor and major inner diameter, wall thickness, inner and outer area, inner and outer perimeter, wall area fraction, and inner equivalent circle diameter) were evaluated. Comparisons were made between control and target protocols using difference and repeatability measures.

RESULTS

Estimated CT volume dose index (CTDIvol) across all protocols ranged from 7.32 mGy to 0.32 mGy. Low- and ultralow-dose protocols required more manual editing and resolved fewer airway branches; yet, comparable pi10 whole lung measures were observed across all protocols. Similar trends in acquired parenchymal and airway measurements were observed across all protocols, with increased measurement differences using the ultralow-dose protocols. However, for small airways (1.9 ± 0.2 mm) and medium airways (5.7 ± 0.4 mm), the measurement differences across all protocols were comparable to the control protocol repeatability across breath holds. Diameters, wall thickness, wall area fraction, and equivalent diameter had smaller measurement differences than area and perimeter measurements.

CONCLUSIONS

In conclusion, the use of IR with low- and ultralow-dose CT protocols with CT volume dose indices down to 0.32 mGy maintains selected quantitative parenchymal and airway measurements relevant to pulmonary disease characterization.

Gene expression profiling of human colon cancer cells following inhibition of signal transduction by 17-allylamino-17-demethoxygeldanamycin, an inhibitor of the hsp90 molecular chaperone

A number of molecular therapeutic agents, derived from exploiting our knowledge of the oncogenic pathways that are frequently deregulated in cancer, are now entering clinical trials. One of these is the novel agent 17-allylamino-17-demethoxygeldanamycin that acts to inhibit the hsp90 molecular chaperone. Treatment of four human colon cancer cell lines with iso-effective concentrations of this agent resulted in depletion of c-raf-1 and akt and inhibition of signal transduction. We have used gene expression array analysis to identify genes responsive to treatment with this drug. The expression of hsp90 client protein genes was not affected, but hsc hsp70, hsp90beta, keratin 8, keratin 18 and caveolin-1 were deregulated following treatment. These observations were consistent with inhibition of signal transduction and suggested a possible mechanism of resistance or recovery from 17-allylamino-17-demethoxygeldanamycin treatment. The results shed light on the molecular mode of action of the hsp90 inhibitors, and suggest possible molecular markers of drug action for use in hypothesis testing clinical trials. Oncogene (2000) 19, 4125 - 4133

A Method for the Analysis of Chlorinated Benzenes in Clams (Mercenaria mercenaria) and Oysters (Crassostrea virginica)

A method of analysis for mixtures of chlorinated benzenes in clam (Mercenaria mercenaria) and oyster (Crassostrea virginica) samples is reported. The method involves Soxhlet extraction with n-hexane-isopropanol (1:1) for 6 hours followed by gas chromatographic separation on a Silicone gum column with an electron affinity detector. Quantities as small as 10-10 g are detectable. Average recovery of added Polystream (a mixture of chlorinated benzenes) was 99% for clam samples and 104% for oyster samples. Recoveries were based on reading the 1,2,3,4-tetrachlorobenzene peak. The relative precision for triplicate chromatograms, averaged over all levels, was ± 5%.