Academic accomplishments of Black neurosurgeons in the United States

OBJECTIVE

Neurosurgery has remained relatively homogeneous in terms of racial and gender diversity, trailing behind national demographics. Less than 5% of practicing neurosurgeons in the United States identify as Black/African American (AA). Research and academic productivity are highly emphasized within the field and are crucial for career advancement at academic institutions. They also serve as important avenues for mentorship and recruitment of diverse trainees and medical students. This study aimed to summarize the academic accomplishments of AA neurosurgeons by assessing publication quantity, h-index, and federal grant funding.

METHODS

One hundred thirteen neurosurgery residency training programs accredited by the Accreditation Council for Graduate Medical Education in 2022 were included in this study. The American Society of Black Neurosurgeons registry was reviewed to analyze the academic metrics of self-identified Black or AA academic neurosurgeons. Data on the academic rank, leadership position, publication quantity, h-index, and race of neurosurgical faculty in the US were obtained from publicly available information and program websites.

RESULTS

Fifty-five AA and 1393 non-AA neurosurgeons were identified. Sixty percent of AA neurosurgeons were fewer than 10 years out from residency training, compared to 37.4% of non-AA neurosurgeons (p = 0.001). AA neurosurgeons had a median 32 (IQR 9, 85) publications compared to 52 (IQR 22, 122) for non-AA neurosurgeons (p = 0.019). AA neurosurgeons had a median h-index of 12 (IQR 5, 24) compared to 16 (IQR 9, 31) for non-AA colleagues (p = 0.02). Following stratification by academic rank, these trends did not persist. No statistically significant differences in the median amounts of awarded National Institutes of Health funding (p = 0.194) or level of professorship attained (p = 0.07) were observed between the two cohorts.

CONCLUSIONS

Racial disparities between AA and non-AA neurosurgeons exist in publication quantity and h-index overall but not when these groups are stratified by academic rank. Given that AA neurosurgeons comprise more junior faculty, it is expected that their academic accomplishments will increase as more enter academic practice and current neurosurgeons advance into more senior positions.

A contemporary analysis of surgical ligation versus endovascular embolization in patients with intracranial dural arteriovenous fistulas: a propensity score-matched and mixed-effects model study

OBJECTIVE

Intracranial dural arteriovenous fistulas (dAVFs) are rare vascular lesions that can be asymptomatic or can lead to devastating hemorrhage based on the dAVF's aggressiveness. Several approaches can be taken to treat dAVFs, such as endovascular embolization and surgical ligation. However, very few studies have evaluated the influence of surgery compared to endovascular approaches on patient outcomes. This study was performed to analyze the clinical characteristics and outcomes of patients who underwent treatment for intracranial dAVF in which either endovascular embolization or microsurgical ligation was used.

METHODS

The Nationwide Readmissions Database was reviewed for all patients who underwent treatment for dAVFs (n = 18,152) between 2016 and 2019. Patients who received only surgical ligation or endovascular embolization (i.e., not both) were included. Variables regarding demographics, clinical outcomes, and healthcare utilization were queried. Primary outcome measures were nonroutine discharge, 1-year readmission, top quartile length of stay (LOS), and top quartile of inpatient all-payer cost. Propensity score matching was performed to evaluate the influence of either surgery or embolization on patient outcomes. Receiver operating characteristic (ROC) curves were created for each outcome measure. The area under the curve (AUC) of each ROC was used to estimate mixed-effects model performance.

RESULTS

Following propensity score matching, 127 and 113 patients made up the surgical ligation and endovascular embolization cohort, respectively. There were no differences found in age (p = 0.16), sex (p = 0.57), or average Elixhauser Comorbidity Index (p = 0.32). Patients receiving surgical ligation had lower odds of readmission (OR 0.37, p = 0.028) and greater odds of nonroutine discharge (OR 2.21, p = 0.03) compared to patients who underwent endovascular embolization. The authors found no differences in the top quartile of LOS (p = 0.84), top quartile of cost (p = 0.38), or mortality (p > 0.99) between cohorts. ROC curves revealed that the mixed-effects models inclusive of approach outperformed models agnostic to approach with respect to nonroutine discharge (AUC with approach, 0.871; AUC without approach, 0.850; p = 0.018) and readmission (AUC with approach, 0.686; AUC without approach, 0.651; p = 0.019), but no differences were observed regarding top quartile of LOS (p = 0.17) and top quartile of cost (p = 0.40).

CONCLUSIONS

Surgical approach may influence perioperative outcomes in patients treated for intracranial dAVF-most significantly discharge disposition and 1-year readmission. Future longitudinal prospective studies with more clinical detail will be required to fully capture the predictive utility of surgical approach in patients treated for intracranial dAVF, particularly for various dAVF subtypes.

Extreme-aged patients (≥ 85 years) experience similar outcomes as younger geriatric patients following chronic subdural hematoma evacuation: a matched cohort study

Subdural hematoma (SDH) evacuation represents one of the most frequently performed neurosurgical procedures. Several reports cite a rise in both the age and number of patient's requiring treatment, due in part to an aging population and expanded anticoagulation use. However, limited data and conflicting conclusions exist on extreme-aged geriatric patients (≥ 85 years of age) after undergoing surgery. Patients undergoing SDH evacuation at a tertiary academic medical center between November 2013-December 2021 were retrospectively identified. The study group consisted of patients ≥ 85 years (Group 1) diagnosed with a chronic SDH surgically evacuated. A control group was created matching patients by 70-84 years of age, gender, and anticoagulation use (Group 2). Multiple metrics were evaluated between the two including length-of hospital-stay, tracheostomy/PEG placement, reoperation rate, complications, discharge location, neurological outcome at the time of discharge, and survival. A total of 130 patients were included; 65 in Group 1 and 65 in Group 2. Patient demographics, medical comorbidities, SDH characteristics, international normalized ratio, partial thromboplastin time, and use of blood thinning agents were similar between the two groups. Kaplan Meier survival analysis at one-year was 80% for Group 1 and 76% for Group 2. No significant difference was identified using the log-rank test for equality of survivor functions (p = 0.26). All measured outcomes including GCS at time of discharge, length of stay, rate of reoperations, and neurological outcome were statistically similar between the two groups. Backwards stepwise conditional logistic regression revealed no significant association between poor outcomes at the time of discharge and age. Alternatively, anticoagulation use was found to be associated with poor outcomes (OR 3.55, 95% CI 1.08-11.60; p = 0.036). Several outcome metrics and statistical analyses were used to compare patients ≥ 85 years of age to younger geriatric patients (70-84 years) in a matched cohort study. Adjusting for age group, gender, and anticoagulation use, no significant difference was found between the two groups including neurological outcome at discharge, reoperation rate, and survival.

Meningioma transformation to glioblastoma following stereotactic radiosurgery: A case report and review of the literature

Background

Meningiomas are the most common primary intracranial tumor with increasing incidence. Stereotactic Radiosurgery Gamma Knife (SRS-GK) is a commonly used modality for neoadjuvant and adjuvant treatment of these tumors and is often necessary for long-term disease control, particularly for the World Health Organization grade II/III meningiomas. While there is strong evidence to support the use of SRS-GK for meningioma, there exists a risk of secondary malignancy that is not well understood. We report a case of glioblastoma (GBM) that arose near the bed of a meningioma previously treated with SRS-GK and discuss other cases of GBM that emerged at a site of meningioma reported in the literature.

Case Description

A 79-year-old female with a history of a blood-clotting disorder presented to the hospital with sudden facial sensory disturbances. On magnetic resonance imaging (MRI), a homogeneously enhancing lesion was observed in the right temporal lobe, consistent with a meningioma. Following 2 years of surveillance, the patient underwent SRS-GK for enlargement of the lesion. The patient later presented with headache and gait instability 12 years following SRS-GK. MRI revealed a large ring-enhancing lesion with surrounding edema histologically confirmed to be a GBM. At 9 months following initial tumor resection and a combination of radiotherapy and temozolomide, the patient was neurologically intact.

Conclusion

There is a very small risk of meningioma to GBM conversion following SRS. Although SRS-GK poses a risk of secondary malignancy, there are some reported cases that underwent malignant transformation without SRS-GK. This suggests that SRS-GK is not the only factor in transformation and is a reasonable therapeutic modality to consider utilizing. Patients and their families should be appropriately counseled on the potential risks of radiation therapy, even for benign lesions like a meningioma.

Comparison between continued inpatient treatment versus day patient treatment after short inpatient care in early onset anorexia nervosa (COTIDEA trial): a study protocol for a non-inferiority randomised controlled trial

BACKGROUND

In children with early-onset anorexia nervosa (first symptoms before 13 years old, EO-AN), experts recommend initial outpatient treatment but in-patient treatment (IP) is frequently indicated due to acute medical instability or for those who have not improved with outpatient treatment. This IP can target either a partial weight restauration or a total weight normalization (return to the previous BMI growth trajectory). There are no evidence in the literature on which is the better therapeutic option in EOAN. But as long length of stay induce social isolation, with elevated costs, we wonder if a stepped-care model of daypatient treatment (DP) after short IP stabilisation may be a treatment option as effective as full-time IP to target weight normalization. We designed a two-arm randomised controlled trial testing the non-inferiority of a stepped-care model of DP after short IP stabilisation versus full-time IP.

METHODS

Eighty-eight children aged 8 to 13 years suffering from EOAN with initial severe undernutrition will be randomly allocated to either IP treatment as usual or a stepped care DP model both targeting weight normalization. Assessments will be conducted at inclusion, somatic stabilization, weight normalization, 6 months and 12 months post randomisation. The primary outcome will be BMI at 12 months post-randomisation. Secondaries outcomes will included clinical (tanner stage), biological (prealbumin, leptin, total ghrelin and IGF1) and radiological (bone mineralization and maturation) outcomes, eating symptomatology and psychiatric assessments, motivation to change, treatment acceptability and quality of life assessments, cost-utility and cost-effectiveness analyses.

DISCUSSION

COTIDEA will provide rigorous evaluation of treatment alternative to full-time inpatient treatment to allow a reduction of social iatrogenic link to hospital length of stay and associated costs.

TRIAL REGISTRATION

Trial is registered on ClinicalTrials.gov (NCT04479683).

Association of mental disorders with costs of somatic admissions in France

OBJECTIVES

Mentally ill patients have worse health outcomes when they suffer from somatic conditions compared to other patients. The objective of this study was to assess the association of mental illness with hospital inpatient costs for somatic reasons.

METHODS

All adult inpatient stays for somatic reasons in acute care hospitals between 2009 and 2013 were included using French exhaustive hospital discharge databases. Total inpatient costs were calculated from the all-payer perspective and compared in patients with and without a mental disorder. Only patients who had been admitted at least once for a mental disorder (either full-time or part-time) were considered to be mentally ill in this study. Generalized linear models with and without interaction terms studied the factors associated with hospital inpatient costs.

RESULTS

17,728,424 patients corresponding to 37,458,810 admissions were included. 1,163,972 patients (6.57%) were identified as having a mental illness. A previous full-time or part-time admission for a mental disorder significantly increased hospital inpatient costs (+32.64%, 95%CI=1.3243-1.3284). Interaction terms found an increased impact of mental disorders on costs in patients with low socio-economic status, as well as in men, patients aged between 45 and 60, and patients with a cardiovascular disease or diabetes.

CONCLUSION

Mentally ill patients have higher hospital costs than non-mentally ill patients. Improving curative and preventive treatments in those patients could improve their health and decrease the burden on healthcare systems.

Intracranial venous sinus thrombosis: Medical and surgical management considerations

Cerebral venous thrombosis is a serious neurological condition characterized by thrombus formation in the venous sinuses or cerebral veins. Although rare, it is a potentially fatal condition that requires prompt diagnosis and treatment. This review aims to present the most current trends in our understanding of CVT risk factors, diagnosis, medical management, role of endovascular management, risk of intracranial hemorrhage, and emerging therapies. Most cases of CVT are diagnosed by clinical features and neuroimaging suggestive of sinus occlusion. While anticoagulation with heparin is the mainstay of medical management, direct-oral anticoagulants are emerging as a potential alternative, and severe cases have been managed successfully with thrombectomy and/or intrasinus urokinase thrombolysis. Despite recent advances in anticoagulation therapy and diagnostics, larger randomized studies are required to adequately assess these emerging therapies and better inform the management of patients suffering from CVT.

Aortic valve replacement for aortic stenosis in France – influence of centers' volumes on TAVR adoption rate and outcomes

Aims

Over the last decade, transcatheter aortic valve replacement (TAVR) became extensively used, now being the recommended as first line procedure for aortic valve replacement (AVR) in selected patients' populations. It is unknown whether TAVR adoption rate and variability in outcomes is influenced by centers' volume.

Methods

From a French administrative hospital-discharge database, we collected all AVR performed in France between 2007 and 2019. Centers were stratified to terciles based on their annual SAVR per year per center during 2007–2009 (“pre TAVR era”).

Results

There was 218,489 AVRs (153,747 SAVR and 74,732 TAVR) performed in 46 centers between 2007–2019. Number of total AVR and even more so number of number of TAVR significantly and linearly increased from 2007 to 2019 in all terciles but faster in the high volume tercile (+17, +17 and +31 AVR/center/year in the low, middle and high terciles respectively, P [ANCOVA]<0.001; +11, + 19 and +33 TAVR/center/year in the low, medium and high tercile respectively, P [ANCOVA] <0.00, Figure 1). The age of patients underwent TAVR remained grossly unchanged in all three terciles, however, the Charlson index declined from 2010 to 2019 (from 1.35±1.42 to 0.65±1.04, from 1.21±1.40 to 0.65±1.05 and from 1.53±1.58 to 0.81±1.21, in the low, middle and high terciles, P for trend <0.001, 0.021, and <0.001, respectively). Charlson score in the years 2017–2019, was higher in the high than middle and low terciles (0.87±1.22, 0.76±1.11 and 0.65±1.04, respectively, P<0.0001). The in-hospital mortality rate for TAVR significantly declined from 2010 to 2019 for TAVR in all terciles (from 8.3% to 2.1%, from 7.5% to 2.5% and from 8.2% to 2.1% for low, middle and high TAVR terciles, respectively; p for trend = 0.002, 0.001 and <0.001, respectively, Figure 2). Average mortality in 2017–2019 was similar in all terciles (2.3%, 2.5% and 2.2% for low, middle and high terciles, respectively, P=0.47). After adjusting for age, sex and Charlson score, mortality was higher in the low tercile compared with middle and high terciles (OR 1.15, P<0.001, confidence interval [CI] 1.0–1.2, and OR 1.18, P<0.001, CI 1.1–1.2, respectively).

Conclusions

From 2007 to 2019 total AVR linearly increased, mostly due to increase in TAVR, irrespective of centers' volume, but increase rate was higher in high volume centers. A constant decline in patients risk profile, with a striking decrease in mortality rate, was observed in all volume terciles. High-volume centers patients' have higher risk profile, with adjusted mortality slightly lower than medium and low volume centers.

Funding Acknowledgement

Type of funding sources: None.

Outcomes following patent foramen ovale percutaneous closure according to the delay from last ischemic event

Background

Randomized controlled trials evaluating patent foramen ovale (PFO) percutaneous closure only included patients with recent embolic event. We aimed to evaluate outcomes following percutaneous PFO closure outcomes according to the delay from the last embolic episode.

Methods

This international ambispective cohort included consecutive patients from two centers in France and Canada undergoing PFO percutaneous closure for secondary prevention of paradoxical embolic event. The primary endpoint was the composite of stroke or transient ischemic attack (TIA). Logistic regression model was used to evaluate determinants of late PFO closure procedures.

Results

A total of 1,179 patients (mean age 49±12.7 years; 44.4% female) underwent PFO closure from 2001 to 2021 (Figure 1). The median delay from last embolic event to procedure was 6.0 (3.4–11.2) months. Determinants of late PFO closure procedure were the center (France versus Canada) adjusted Odds Ratio (aOR) 1.65 95% confidence interval (CI) 1.25–2.19, year of procedure (≥2018 versus <2018) aOR 1.43 95% CI 1.08–1.90, female sex aOR 1.63 95% CI 1.28–2.07 and lower RoPE score aOR 1.10 95% CI 1.03–1.19. After a median follow-up of 2.61 (1.13–7.25) years, the incidence rate of first stroke or TIA did not differ between early and late PFO procedures with 0.51 versus 0.29 events per 100 patient-years, respectively, incidence rate ratio 1.74 95% CI 0.66–5.08, p=0.25 (Figure 2). In univariate analysis, late PFO percutaneous closure was not associated with the occurrence of stroke or TIA, with hazard ratio 0.54 95% CI 0.22–1.34 p=0.17.

Conclusion

This analysis provides indirect evidence that delay from last ischemic event does not impact outcomes following PFO percutaneous closure for secondary prevention.

Funding Acknowledgement

Type of funding sources: None.

Evaluating the impact of substrate addition for anaerobic co-digestion on biogas production and digestate quality: The case of deinking sludge

To reduce greenhouse gas emissions from organic waste, anaerobic digestion has created new opportunities for energy and nutrient recovery from these wastes. However, the use of certain organic wastes in anaerobic digestion is limited due to their atypical physicochemical characteristics (e.g. unbalanced carbon to nitrogen ratio, high ash concentration). Deinking sludge is a residue from the paper recycling industry and is one of such substrates. This study aims at evaluating the impact of deinking sludge (DS) addition into a conventional co-digestion mixture on methane production and digestate quality. To this end, an integrated method was proposed, combining the analysis of physicochemical and biodegradability characteristics with parsimonious modeling using the SYS-Metha tool. The measured characteristics of the deinking sludge showed that its potential use in mono-digestion conditions is very limited. When co-digested with food waste and municipal sludge, no significant synergies or antagonisms were found. Based on these experiments, model simulations were executed to determine the optimal conditions for co-digestion with food waste and municipal sludge. A maximum of 22% of deinking sludge on a fresh mass basis can be added into a co-digestion mixture to achieve proper wet anaerobic digestion conditions. Regarding digestate quality, the addition of DS reduced nutrient and contaminants concentrations, which have an impact on digestate management, particularly for land application. Overall, the proposed methodology in this study allows determining optimal co-digestion mixtures and highlighted the limits needing further investigation under pilot/real conditions.

Microbiome and Neurotrauma: Emerging Innovations

The gut-brain axis plays an important role in bidirectional communication that exists and can be altered by injury. Neurotrauma provides acute alteration in the GI tract and alters autonomic function. In this focused review, we highlight what is known about GI disruption following neurotrauma. We then delve into how this affects recovery. Areas of innovation and emerging pre-clinical results are addressed. Finally, we address the link between neurotrauma induced GI dysfunction and progression to neurodegenerative disease states.

CNS Lymphoma: Clinical Pearls and Management Considerations

Primary CNS lymphoma presents unique challenges for the clinician. New evidence has emerged regarding the appropriate workup, management considerations, and treatment. In this paper, we highlight the clinical presentations, disease prognosis, and management considerations. We place specific emphasis on the decision tree for immunocompetent and immunocompromised. The key imaging characteristics are discussed. Once biopsy prove lymphoma, important management considerations are addressed. We highlight need for follow up and role for surgery verse radiation. Finally, we present emerging treatment options and pre-clinical work that will be making its way through the pipeline. This up-to-date review will serve as a key learning tool for clinicians and researchers.

Le déficit en interféron de type I n’altère pas la réponse lymphocytaire B mémoire contre le SARS-CoV-2 après vaccination par ARNm

Introduction

Les vaccins à ARN messagers ont joué un rôle majeur dans la lutte contre la pandémie de SARS-CoV-2 grâce à une excellente efficacité et sécurité clinique. Ces vaccins ont été développés suite à des années de recherche fondamentale, dont l’une des étapes cruciales a été de remplacer l’uridine de l’ARNm par de la 1-méthyl-pseudo-uridine afin d’éviter la reconnaissance par les récepteurs de l’immunité innée, notamment le toll-like-receptor (TLR) 7. Une hypothèse, très fréquemment défendue mais jamais étayée expérimentalement, est que cet ARN modifié garde une activité immunostimulatrice à bas bruit permettant la production d’interféron de type I, agissant comme un adjuvant du vaccin. Les interférons de type I sont des cytokines antivirales essentielles et les patients ayant un déficit dans les voies de l’interféron de type I sont à haut risque de COVID-19 sévère. Dans ce travail, nous avons analysé la réponse lymphocytaire B au vaccin à ARNm de patients présentant l’absence de signalisation par les interférons de type I. Ceci nous a permis de savoir si les vaccins par ARNm permettaient d’établir une réponse lymphocytaire B robuste en l’absence d’interféron de type I.

Patients et méthodes

Nous avons constitué trois cohortes de patients (i) des patients avec des déficits génétiques sur les voies de l’interféron de type I : 2 patients avec une mutation homozygote d’IRF7 (facteur de transcription responsable de la production d’interférons de Type I, notamment en aval de TLR7) et un patient avec une déficit hémizygote de TLR7 (ii) des patients ayant des auto-anticorps neutralisant les interférons alpha et oméga, dans le cadre d’une polyendocrinopathie auto-immune de type I (APS-1, n = 14) (iii) des patients ayant des auto-anticorps neutralisant les interféron, associés à l’âge, une entité récemment décrite et particulièrement fréquente chez les sujets âgés (n = 8). Ces sujets ont été comparés à 29 contrôles sains. Tous étaient naïfs du COVID-19 et ont reçu 2 doses de vaccin à ARNm (BNT162n2 ou mRNA1273). Les patients ont été prélevés à différents point de temps, dans les 3 premiers mois et entre 3 et 7 mois après la seconde dose. La réponse sérologique a été évaluée par ELISA anti-IgG et IgA RBD (receptor binding domain de la Spike) et la neutralisation sérique a été testée in vitro contre le D614G-SARS-CoV-2. Les lymphocytes B (LB) mémoires CD19 + IgD-CD27± spécifiques du RBD ont été analysés en cytométrie en flux et triés en cellule unique pour séquençage des régions variables de la chaîne lourde de l’immunoglobuline.

Résultats

La réponse sérologique anti-RBD IgG et IgA était comparable aux temps précoces et tardifs de la réponse vaccinale, évoluant de façon similaire chez les patients déficients en interféron de type I et les sujets sains. La capacité de neutralisation des sérums contre le SARS-CoV-2 était également identique dans tous les groupes, et corrélait fortement avec le taux d’IgG anti-RBD, suggérant que le RBD était également la cible de la réponse neutralisante chez les patients déficients en interféron de type I. Des LB mémoires circulants spécifiques du RBD étaient retrouvés dans toutes les cohortes de patients déficients en interféron de type I au cours des 3 mois suivant la vaccination. Ceux-ci se maintenaient dans le temps et étaient encore présents entre 3 et 7 mois après la vaccination (0,18 % des LB IgD-CD27+ chez les sujets sains, 0,24 % chez les sujets avec déficit génétiques, 0,16 % chez les APS-1 et 0,26 % chez les AAB, pas de différence statistiquement significative). Le séquençage de la chaîne lourde des régions variables de l’immunoglobuline des LB mémoires spécifiques du RBD révélait l’accumulation progressive des mutations jusqu’à 7 mois chez les sujets sains, témoignant d’une réaction des centres germinatifs permettant la maturation d’affinité et la génération de lymphocytes B mémoires à longue durée de vie. Chez les patients IRF7 déficients, les LB mémoires spécifiques du RBD acquerraient progressivement des mutations de M1 à M6, et les LB mémoires spécifiques du RBD de patients TLR7 et APS-1 arboraient un nombre élevé de mutation dès M4, témoignant que même en l’absence de réponse à l’interféron de type I, le vaccin permettait la génération des LB mémoire issus des centres germinatifs, comme chez les sujets sains. Enfin, des clones partagés étaient retrouvés entre les sujets sains et les patients déficient en interféron de type I témoignant d’une réponse qualitativement normale.

Conclusion

Notre travail apporte des données rassurantes sur la vaccination de ces patients à haut risque de forme de grave de COVID-19 et suggère que l’ARNm contenu dans les vaccins n’a pas de rôle adjuvant intrinsèque.

Diabetes management in spinal surgery

Diabetes mellitus can lead to long-standing complications in multiple arenas. An area that is often overlooked is implications for major surgery. Spinal decompression and fusions have unique challenges in the diabetic patient. In this review, we briefly highlight the pathophysiology of diabetes mellitus prior to examining implications for spinal surgery. We focus on the wound healing process, surgical infection risk, and delayed fusion. The paper then transitions to a focus on early diagnostics as well as pre-operative glucose control. Finally, we highlight important management strategies post operatively, continued necessity of monitoring, and emerging treatment and diagnostic approaches. This paper will serve as a key clinical guide that clinicians can utilize for diagnostic, management, and follow-up planning.

Spinal Cord Injury: A Review of Current Management Considerations and Emerging Treatments

Traumatic spinal cord injuries can have devastating outcomes for patients. In this focused review, we discuss the epidemiology of spinal cord injuries, associated neurologic exam findings, and primary and secondary injury progression. We then delve into the emerging treatment approaches and relevance to improving outcomes. The disease is multifactorial and has many management considerations. This concise user-friendly resource can help guide clinicians caring for these patients. Also, it points to the need for continued scientific discovery and improved pharmaceutical and device innovations.

La vaccination par ARNm des sujets naïfs ou convalescents de la COVID-19 permet la génération de lymphocytes B mémoires capables de reconnaître et de neutraliser les variants du SARS-CoV-2

Introduction

La mémoire immunitaire est un mécanisme qui protège les individus contre la réinfection. Cette stratégie de défense de l’organisme, qui est à la base du succès des vaccins, comprend la production d’anticorps protecteurs dans le sang ainsi que la formation de cellules à mémoire, capables de se réactiver rapidement en cellules productrices d’anticorps lors d’une nouvelle infection. Les vaccins à ARNm, codant pour la protéine Spike du SARS-CoV-2, ont été rapidement déployés dans le monde entier, avec une grande efficacité clinique. Déterminer les caractéristiques de la réponse lymphocytaire B mémoire générée par ces vaccins est d’une importance majeure, notamment dans le contexte de circulation de variants du SARS-CoV-2, porteurs de mutations dans la protéine Spike. Nous avons étudié la dynamique, l’évolution clonale, et l’affinité des cellules B à mémoire chez des patients vaccinés par le vaccin à ARNm, ainsi que leur capacité à reconnaître et à neutraliser les variants du SARS-CoV-2 dans deux cohortes longitudinales de patients, l’une infectée lors de la première vague (convalescents-vaccinés), et l’autre n’ayant pas été infectée (naïfs-vaccinés).

Patients et méthodes

Les patients infectés lors de la première vague de la pandémie ont été inclus dans l’étude MEMO-CoV2. Une partie de ces patients avec une forme sévère hospitalisée, ou une forme modérée ambulatoire ont reçu une dose de vaccin à ANR messager (BNT162b2) un an après l’infection. De façon parallèle, une cohorte de soignants, naïfs de toute infection et avec une sérologie négative, ont été vaccinés avec deux doses de vaccin à ARNm. Ces deux cohortes ont été suivies et analysées (Sérologie, Cytométrie en flux des cellules B) longitudinalement jusqu’à 2 mois après le boost vaccinal (première injection pour les convalescents, deuxième injection pour les naïfs). Les cellules B mémoires spécifiques du domaine RBD de la protéine Spike ont été isolées, triées et cultivées en cellule unique. Pour chaque cellule anti-RBD mémoire, nous avons séquencé la chaîne lourde de l’immunoglobuline et nous avons déterminé l’affinité par Biolayer-interferometry des anticorps produits contre des variants préoccupants(α, β, γ et δ). Nous avons aussi déterminé pour certains clones leur capacité à neutraliser le virus D614G (dominant lors de la première vague) et β in vitro.

Résultats

La vaccination induisait une réponse sérologique IgG anti-RBD robuste chez tous les patients analysés (n = 47). L’activité neutralisante du sérum contre le virus D614G était excellente pour tous les patients. Néanmoins, la neutralisation sérique des variants β et δ était très nettement meilleure chez les patients déjà infectés, suggérant que les plasmocytes mobilisés lors du boost vaccinal proviennent de cellules mémoires matures. L’analyse en cytométrie en flux, a mis en évidence une expansion du pool mémoires chez les patients convalescents à un niveau supérieur à celui des naïfs. L’analyse de plus de 2400 séquences de la chaîne lourde de l’immunoglobuline provenant de cellules B mémoires anti-RBD cultivés en cellule unique, a révélé que la réponse vaccinale anti-RBD mobilise des cellules peu mutées, donc nouvellement générées, chez les individus naïfs. À l’inverse les cellules mémoires mobilisées après le boost chez patients convalescents arboraient de nombreuses mutations somatiques, témoignant de la mobilisation de mémoires préexistantes. L’analyse du répertoire des cellules B mémoires montrait que sa diversité était conservée après la vaccination malgré son expansion. Nous avons ensuite analysé l’affinité de 382 anticorps monoclonaux issus cellules B mémoires mobilisées par le boost vaccinal, contre le RBD de différent variants (α, β, γ, δ, κ). L’affinité des anticorps contre la RBD sauvage était plus forte chez les convalescents que chez les naïfs et corrélait avec le nombre de mutations somatiques dans la chaine lourde de l’immunoglobuline, reflétant le processus de maturation d’affinité. Des clones de très haute affinité contre tous les RBD variants étaient détectés chez tous les individus testés, y compris chez les naïfs, ainsi que des clones neutralisant le variant β, qui a la plus grande capacité à échapper à la réponse immune.

Conclusion

Chez les patients convalescents, la vaccination amplifie un large répertoire de cellules B mémoires matures et génère des plasmocytes neutralisant les variants. Chez les individus naïfs, la vaccination induit un pool de mémoire contenant des clones neutralisants puissants contre tous les variants préoccupants actuels, dont bêta et delta. Nos résultats suggèrent qu’une troisième dose chez les sujets naïfs permettrait de différentier en plasmocytes les lymphocytes B mémoires de grande qualité générés par le schéma vaccinal initial et ainsi d’augmenter l’activité neutralisante des sérums contre les variants du SARS-CoV-2.

Cost-utility of oral methylprednisolone in the treatment of multiple sclerosis relapses: Results from the COPOUSEP trial

BACKGROUND

Studies have shown that oral high-dose methylprednisolone (MP) is non-inferior to intravenous MP in treating multiple sclerosis relapses in terms of effectiveness and tolerance. In order to assist with resource allocation and decision-making, its cost-effectiveness must also be assessed. Our objective was to evaluate the cost-utility of per os high-dose MP as well as the cost-savings associated with implementing the strategy.

METHODS

A cost-utility analysis at 28 days was carried out using data from the French COPOUSEP multicenter, double-blind randomized controlled non-inferiority trial and the statutory health insurance reimbursement database. Costs were calculated using a societal perspective, including both direct and indirect costs. An incremental cost-effectiveness ratio was calculated and bootstrapping methods assessed the uncertainty surrounding the results. An alternative scenario analysis in which MP was administered at home was also carried out. A budgetary impact analysis was carried at five years.

RESULTS

In the conditions of the trial (hospitalized patients), there was no significant difference in utilities and costs at 28 days. The incremental cost-effectiveness ratio was €15,360 per quality-adjusted life-year gained. If multiple sclerosis relapses were treated at home, oral MP would be more effective, less costly and associated with annual savings up to 25 million euros for the French healthcare system.

CONCLUSIONS

Oral MP is cost-effective in the treatment of multiple sclerosis relapses and associated with major savings.

Tocilizumab and COVID-19: timing of administration assessment

Recent evidence showed greater efficacy of tocilizumab (TCZ) in the subgroups of COVID-19 patients who presented with symptoms for less than 7 days and in those only receiving oxygen. We retrospectively analyzed a compassionate use cohort to determine the best timing for TCZ injection. We showed no association between the timing of injection after symptom onset and the efficacy of TCZ on mortality. We then investigated whether the oxygen level at the time of TCZ injection impacted the mortality rate. Our study finally suggested that TCZ could be less effective when oxygen requirement is > 11 L/min and we hypothesized that earlier administration could be associated with better outcome. However, randomized clinical trials are required to confirm this hypothesis.

Applicability and safety of discontinuous ADVanced Organ Support (ADVOS) in the treatment of patients with acute-on-chronic liver failure (ACLF) outside of intensive care

BACKGROUND

ADVanced Organ Support (ADVOS) is a novel type of extracorporeal albumin dialysis and holds promise to sustain liver function and recovery of patients with acute-on-chronic liver failure (ACLF). Previously, ADVOS was tested as continuous treatment for intensive care patients with liver failure. Data related to the applicability and safety as discontinuous treatment outside of ICU is not available.

AIM

Evaluation of ADVOS as discontinuous treatment for patients with ACLF outside intensive care unit and comparison with a matched historic cohort.

METHODS AND RESULTS

In this retrospective study, 26 patients with ACLF and the indication for renal replacement therapy related to HRS-AKI were included. Majority of patients were male (65%) with alcoholic cirrhosis in 88% and infections as a trigger of ACLF in 96%. Liver function was severely compromised reflected by high median MELD and CLIF-C ACLF scores of 37 (IQR 32;40) and 56.5 (IQR 51;60), respectively. Patients were treated discontinuously with ADVOS over a median time of 12 days (IQR 8.25;17) and received 8 (IQR 4.25;9.75) treatment cycles on average. No treatment related adverse events were recorded, and safety laboratory parameters remained constant during the observation time. After 16 h cumulative dialysis therapy, ADVOS significantly reduced protein-bound bilirubin (14%), creatinine (11.8%) and blood urea nitrogen (BUN, 33%). Using a matched cohort with ACLF treated with hemodialysis, ADVOS achieved a stronger decrease in bilirubin (p = 0.01), while detoxification of water-soluble catabolites' including creatinine and BUN was comparable. The 28-days mortality in the ADVOS group was 56% (14/26) and was not inferior to predicted survival (predicted median 28-days mortality was 44%, IQR 30; 59).

CONCLUSION

Discontinuous ADVOS treatment was safe and effective in patients with ACLF outside intensive care and outperformed hemodialysis in reducing protein-bound metabolites.