A new variant of gallbladder duplication mimicking a choledochal cyst: stepwise management of an unexpected surgical finding

We present a case of previously unclassified duplicated gallbladder which posed a surgical challenge intraoperatively by mimicking a choledochal cyst. An intraoperative cholangiogram was performed followed by a simple cholecystectomy. No further dissection was performed to avoid bile duct injury and complication from the unconventional anatomy. Postoperative imaging and histology, followed by the second operation confirmed findings consistent with the duplicated gallbladder. Through this case, we have demonstrated the principles of safe cholecystectomy and the importance of a staged approach in an unanticipated encounter of anatomical uncertainty, as well as the description of a new variant of duplicated gallbladder.

Shedding light on eye disease in obesity: A review

Obesity is known to be associated with numerous ocular manifestations, including but not limited to, diabetic retinopathy (DR), age-related macular degeneration (AMD), cataracts, glaucoma, and dry eye disease. This review aims to provide an overview of the ophthalmological findings in obesity. A literature search was conducted using PubMed and Cochrane databases for studies describing randomized clinical trials, meta-analyses, systematic reviews, and observational studies published from 1 January 2017 to 1 April 2023. The search terms used included relevant keywords such as 'obesity', 'body mass index', 'waist-to-hip ratio', 'bariatric', 'ophthalmology', 'eye disease', 'myopia', 'retinopathy', 'glaucoma', and 'cataract'. This literature search was performed on 1 April 2023. Obesity is associated with increased risk of developing DR, a sight-threatening complication of diabetes mellitus. Similarly, obesity has been shown to increase risk of AMD, cataracts, glaucoma, and ocular surface disease. Multiple mechanisms linking obesity to ophthalmic disease have been proposed. Adipose tissue produces various inflammatory cytokines that can affect ocular tissues, leading to disease progression. Additionally, obesity is associated with systemic metabolic changes that can influence ocular health. Bariatric surgery has been shown to be protective against development of ophthalmic disease. Obesity is a significant risk factor for several ophthalmological diseases. Healthcare providers should encourage weight loss in patients with overweight or obesity to prevent or delay the onset of ocular complications. Further research is needed to better understand the underlying mechanisms of this association, and to identify effective strategies for preventing or managing ophthalmic disease in patients with obesity.

Exploration of AI-Assisted On-Board Perfusion Imaging Technique on Patients Undergoing Thoraxradiotherapy

PURPOSE/OBJECTIVE(S)

Pulmonary function of lung cancer patients can significantly change along the radiation therapy (RT) course. Scholars have synthesized lung function maps from computed tomography (CT) images. Still, there is lack of study exploring the feasibility of generating lung perfusion information from cone-beam CT (CBCT). Our study aims to fill up this gap in the body of literatures.

MATERIALS/METHODS

One-hundred-and-six pairs of planning CT and CBCT images of thoracic cancer patients from XX hospital were collected retrospectively. All CT images were registered to CBCT with a deformable algorithm, and referred as deformed planning CT (dCT). A 2D convolutional neural network (CNN) model built with cycle generative adversarial network (cycle-GAN) was trained to correct CBCT image artifacts and HU value discrepancies. The corrected CBCT was named enhanced CBCT (eCBCT) in this study. All CBCT, eCBCT and dCT images were then input to a pre-trained CT-to-perfusion deep learning (DL) model to synthesize perfusion images (PI), namely PICBCT, PIeCBCT and PIdCT respectively. For model training, 80 image pairs were assigned to the training set while others to the testing set. dCT and PIdCT were respectively regarded as the ground truth in two consecutive models. One extra validation case acquired with SPECT perfusion scan was collected for model performance test. Quantitative evaluation was done between the ground truth and the synthesized images. Peak signal-to-noise ratio (PSNR) and mean absolute error (MAE) were computed to assess efficacy of CBCT enhancement. Correlation (R) and Dice similarity coefficient (DSC) were used to evaluate voxel-wise and function-wise concurrence in CBCT-derived perfusion mapping.

RESULTS

In CBCT enhancement, [eCBCT-dCT] pairs demonstrated higher agreement than [CBCT-dCT] pairs. Quantitatively, PSNR and MAE were improved from 21.10±1.60 to 24.08±1.76, and 68.99±13.51 to 47.06±11.31 (p<0.01), respectively. For perfusion translation, higher correlation was demonstrated in both voxel-wise and function-wise evaluation within [PIeCBCT-PIdCT] than [PICBCT-PIdCT]. R correlation increased from 0.84±0.09 to 0.89±0.06 (p<0.01), whereas DSC in high-functional regions increased from 0.77±0.06 to 0.82±0.05 (p<0.01). In the validation case, strong correlation was observed between SPECT perfusion scan and PIeCBCT, with R increasing from 0.57 to 0.65 when compared to PICBCT.

CONCLUSION

We proposed a novel DL framework that synthesized perfusion images from fractionally acquired CBCT. Our framework met the clinical needs in providing real-time lung perfusion maps. It can be used to track the continuously changing pulmonary function status throughout the RT course using routinely scanned CBCT, without additional imaging modalities. The framework can facilitate functionally guided adaptive radiation therapy by providing immediate pulmonary function information.

Multi-breed host rumen epithelium transcriptome and microbiome associations and their relationship with beef cattle feed efficiency

Understanding host-microbial interactions in the rumen and its influence on desirable production traits may lead to potential microbiota manipulation or genetic selection for improved cattle feed efficiency. This study investigated the host transcriptome and its correlation with the rumen archaea and bacteria differential abundance of two pure beef cattle breeds (Angus and Charolais) and one composite beef hybrid (Kinsella) divergent for residual feed intake (RFI; low-RFI vs. high-RFI). Using RNA-Sequencing of rumen tissue and 16S rRNA gene amplicon sequencing, differentially expressed genes (FDR ≤ 0.05, |log2(Fold-change) >|2) and differentially abundant (p-value < 0.05) archaea and bacteria amplicon sequence variants (ASV) were determined. Significant correlations between gene expression and ASVs (p-value < 0.05) were determine using Spearman correlation. Interesting associations with muscle contraction and the modulation of the immune system were observed for the genes correlated with bacterial ASVs. Potential functional candidate genes for feed efficiency status were identified for Angus (CCL17, CCR3, and CXCL10), Charolais (KCNK9, GGT1 and IL6), and Kinsella breed (ESR2). The results obtained here provide more insights regarding the applicability of target host and rumen microbial traits for the selection and breeding of more feed efficient beef cattle.

Time-driven Activity-based Costing Analysis of Fluorescein Angiography

PURPOSE

To use electronic health record (EHR) time logs and time-driven activity-based costing (TDABC) to calculate the complete cost profile of office-based fluorescein angiography (FA).

DESIGN

Economic analysis.

SUBJECTS

Patients undergoing routine FA (Current Procedural Terminology [CPT] 92235) at Vanderbilt Eye Institute in fiscal year 2022.

METHODS

Process flow mapping for routine FA was used to define the care episode after manual observation. Deidentified time logs were sourced from the EHR and all manually validated to calculate durations for each stage. The cost of materials was calculated from internal financial figures. Cost per minute for space, equipment, and personnel were based on internal figures. Published fluorescein costs were used for base-case analysis with scenario analysis based on a range of internal figures from pharmacy quotes. These inputs were used for a TDABC analysis.

MAIN OUTCOME MEASURES

Time-driven activity-based costing of FA episode of care. Secondary scenario analyses focus on breakeven scenarios for key inputs, including medication costs RESULTS: Cost analysis of office-based FA resulted in an average total cost of $152.95 (nominal) per interpreted study per patient, which was $36.52 more than the maximum Medicare reimbursement for CPT 92235 in Mac Locality for Tennessee 10312 for fiscal year 2022 ($116.43; $76.11 [technical component] and $40.33 [physician component]). The negative contribution margin is strongly influenced by the cost of fluorescein, which comprises 39.8% of the episode costs, excluding overhead.

CONCLUSIONS

The current analysis here shows that the recently increased cost of fluorescein has driven up the cost of office-based FA relative to the current maximum allowable Medicare reimbursement, leading to a negative contribution margin and financial loss. Given conservative cost estimates here, it is unlikely for profitability to be achieved without changes in the cost of fluorescein or increased reimbursement. These results may be informative for policy discussion regarding appropriate reimbursement for codes using injectable fluorescein.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The miR-124-AMPAR pathway connects polygenic risks with behavioral changes shared between schizophrenia and bipolar disorder

Schizophrenia (SZ) and bipolar disorder (BP) are highly heritable major psychiatric disorders that share a substantial portion of genetic risk as well as their clinical manifestations. This raises a fundamental question of whether, and how, common neurobiological pathways translate their shared polygenic risks into shared clinical manifestations. This study shows the miR-124-3p-AMPAR pathway as a key common neurobiological mediator that connects polygenic risks with behavioral changes shared between these two psychotic disorders. We discovered the upregulation of miR-124-3p in neuronal cells and the postmortem prefrontal cortex from both SZ and BP patients. Intriguingly, the upregulation is associated with the polygenic risks shared between these two disorders. Seeking mechanistic dissection, we generated a mouse model that upregulates miR-124-3p in the medial prefrontal cortex. We demonstrated that the upregulation of miR-124-3p increases GRIA2-lacking calcium-permeable AMPARs and perturbs AMPAR-mediated excitatory synaptic transmission, leading to deficits in the behavioral dimensions shared between SZ and BP.

How should we secure the cystic duct during laparoscopic cholecystectomy? A UK-wide survey of clinical practice and systematic review of the literature with meta-analysis

INTRODUCTION

It is currently unknown which method of cystic duct closure is most effective at reducing the risk of bile leak after laparoscopic cholecystectomy. The aims of this work were to determine the most common closure methods used in the UK and review available evidence on which method has the lowest risk of bile leak.

METHODS

We conducted an online survey through the Association of Upper Gastrointestinal Surgeons (AUGIS). We also undertook a systematic review using PubMed, EMBASE, MEDLINE and the Cochrane Library for studies that compared different methods for cystic duct occlusion and reported postoperative bile leak.

FINDINGS

There was significant variation in practice between consultant surgeons. For routine laparoscopic cholecystectomy metal clips were used most (64%) followed by locking polymer clips (33%) and suture ties (3%). In cases of a dilated cystic duct, preferences were locking polymer clips (60%), suture ties (30%) and metal clips (5%). We included six studies in our review with a total of 8,011 patients. Metal clips were associated with an increased odds of bile leak compared with locking polymer clips (OR 5.66, 95% CI 1.13-28.41, p=0.04) or suture ties (OR 4.17, 95% CI 0.72-24.31, p=0.12). Most studies were retrospective, unlikely to be adequately powered, and vulnerable to selection bias.

CONCLUSIONS

Limited available evidence suggests that metal clips have the highest risk of bile leak, but results are not strong enough to recommend a change in current clinical practice. A trial is now required to determine the best method of cystic duct closure.

680 An Incidental Finding of Pneumatosis of the Colon in a Patient with Mesothelioma Being Treated with Nivolumab

A 75-year-old woman attended a large academic teaching hospital for a computed tomography (CT) of the chest for a T3 N0 M0 epithelioid mesothelioma of the right pleura (to assess treatment response). The malignancy was diagnosed one year previously, and the patient was being treated with second line immunotherapy, Nivolumab (a human immunoglobulin G4 monoclonal antibody) with palliative intent. To date, the patient was showing a partial response to this treatment.

The CT chest incidentally showed locules of gas under the right diaphragm and therefore an urgent CT of the abdomen and pelvis was performed. This scan re-demonstrated a small pneumoperitoneum, but also an incidental finding of pneumatosis involving the hepatic flexure. Prior to Nivolumab treatment, there were no abnormalities noted on the most recent abdominal CT scan.

The patient was admitted to hospital as an emergency under the care of oncology. The patient was entirely asymptomatic with a soft, non-tender abdomen, with both a normal diet and bowel function. Observations including heart rate, temperature, blood pressure and respiratory rate were within normal limits. Blood testing showed a C-reactive protein of 86 mg/L and white cell count of 4.8 10^9. Based on the radiological findings, intravenous fluids and antibiotics were commenced and the patient was restricted to nil intake orally. A surgical review was also requested. Based on surgical advice, the patient was treated conservatively, and was discharged home without complication and no surgical follow up.

Glycated haemoglobin and the risk of postoperative complications in people without diabetes: a prospective population-based study in UK Biobank

Summary

The aim of our study was to clarify the association between glycated haemoglobin (HbA_1c) and postoperative outcomes in people without an existing diagnosis of diabetes. Half a million adults were recruited into the UK Biobank prospective cohort study between March 2006 and October 2010. We divided participants into three groups: no diagnosis of diabetes and HbA_1c < 42 mmol.mol⁻¹; no diagnosis of diabetes and elevated HbA_1c (≥ 42 mmol.mol⁻¹ with no upper limit); and prevalent diabetes (regardless of HbA_1c concentration) at recruitment. We followed up participants by linkage with routinely collected hospital data to determine any surgical procedures undertaken after recruitment and the associated postoperative outcomes. Our main outcome measure was a composite primary outcome of 30‐day major postoperative complications and 90‐day all‐cause mortality. We used logistic regression to estimate the odds of the primary outcome by group. We limited analyses to those who underwent surgery within one year of recruitment (n = 26,653). In a combined effects logistic regression model, participants not known to have diabetes with HbA_1c ≥ 42 mmol.mol⁻¹ had increased odds of the primary outcome (OR [95% CI] 1.43 [1.02–2.02]; p = 0.04), when compared with those without diabetes and HbA_1c < 42 mmol.mol⁻¹. This effect was attenuated and no longer statistically significant in a direct effects model with adjustment for hyperglycaemia‐related comorbidity (OR [95% CI] 1.37 [0.97–1.93]; p = 0.07). Elevated pre‐operative HbA_1c in people without diabetes may be associated with an increased risk of complications, but the association is likely confounded by end‐organ comorbidity. In contrast to previous evidence, our findings suggest that to prevent adverse postoperative outcomes, optimisation of pre‐existing morbidity should take precedence over reducing HbA_1c in people without diabetes.

The role of anticoagulation for superior sagittal sinus thrombosis following craniotomy for resection of parasagittal/parafalcine meningiomas

OBJECTIVE

The safety and efficacy of anticoagulation in managing superior sagittal sinus (SSS) thrombosis remains unclear. The present study investigated the relationship between anticoagulation and cerebrovascular complications in parasagittal/parafalcine meningioma patients presenting with post-surgical SSS thrombosis.

METHODS

We analyzed 266 patients treated at a single institution between 2005 and 2020. Bivariate analysis was conducted using the Mann-Whitney U test and Fisher's exact test. Multivariate analysis was conducted using a logistic regression model. Blood thinning medications investigated included aspirin, warfarin, heparin, apixaban, rivaroxaban, and other novel oral anticoagulants (NOACs). A symptomatic SSS thrombosis was defined as a radiographically apparent thrombosis with new headaches, seizures, altered sensorium, or neurological deficits.

RESULTS

Our patient cohort was majority female (67.3%) with a mean age ([Formula: see text] SD) of 58.82 [Formula: see text] 13.04 years. A total of 15 (5.6%) patients developed postoperative SSS thrombosis and 5 (1.9%) were symptomatic; 2 (0.8%) symptomatic patients received anticoagulation. None of these 15 patients developed cerebrovascular complications following observation or anticoagulative treatment of asymptomatic SSS thrombosis. While incidence of any other postoperative complications was significantly associated with SSS thrombosis in bivariate analysis (p = 0.015), this association was no longer observed in multivariate analysis (OR = 2.15, p = 0.16) when controlling for patient age, sex, and anatomical location of the tumor along the SSS.

CONCLUSIONS

Our single-institution study examining the incidence of SSS thrombosis and associated risk factors highlights the need for further research efforts better prognosticate this adverse outcome. Conservative management may represent a viable treatment strategy for patients with SSS thrombosis.

Burnout among medical students interested in neurosurgery during the COVID-19 era

Objective

The novel Coronavirus Disease 2019 (COVID-19) pandemic has posed unprecedented new stressors to medical student education. This national survey investigated the prevalence of burnout in U.S. medical students interested in pursuing neurosurgical residency during the COVID-19 pandemic.

Methods

A 24-question survey was sent to all American Association of Neurological Surgeons (AANS) medical student chapter members. The abbreviated Maslach Burnout Inventory (aMBI) was used to measure the following burnout metrics: emotional exhaustion, depersonalization, and personal accomplishment. Bivariate analyses were conducted and multivariate analyses were performed using a logistic regression models.

Results

254 medical students were included (response rate of 14.5%). The majority were male (55.1%), White (66.1%), and between their 2nd and 3rd years in medical school (62.6%). Burnout was identified in 38 (15.0%) respondents, a rate lower than reported in the pre-COVID era. In multivariate analysis, burnout was significantly associated with choosing not to pursue, or feeling uncertain about pursuing, a medical career again if given the choice (OR = 3.40, p = 0.0075), having second thoughts about choosing to pursue neurosurgery (OR = 3.47, p = 0.0025), attending a medical program in the Northeast compared to the Southeast (OR = 0.32, p = 0.027) or Southwest U.S. (OR = 0.30, p = 0.046), and indicating that one’s future clinical performance will have worsened due to COVID-19 (OR = 2.71, p = 0.025).

Conclusions

Our study demonstrates relatively low rates of burnout among U.S. medical students interested in pursuing neurosurgery during the COVID-19 pandemic. Our findings also demonstrate multiple factors may aid in early identification of burnout, highlighting potential opportunities for intervention.

Genetic counseling and testing for hereditary hemorrhagic telangiectasia

Genetic counseling is an important means of identifying a patient's genetic risk of hereditary hemorrhagic telangiectasia (HHT) and assisting patients in making informed decisions about their health. With an increase in understanding of the genetic mechanisms underlying HHT over the last decade, genetic counseling is increasingly being incorporated into the care of patients affected by HHT. In addition to refining the diagnosis of symptomatic patients, genetic testing can help to distinguish asymptomatic, at-risk patients from those who are unaffected by HHT. The purpose of this review article is to summarize the current knowledge regarding the role of genetic counseling and genetic testing in identifying and managing HHT in at-risk populations. This article also reviews the guidelines, outcomes, risks, and challenges of genetic counseling and testing for HHT in various patient populations, and provides an algorithm for the use of genetic counseling in symptomatic and asymptomatic patients.

Impact of the COVID-19 pandemic on interventional radiology services across the world

AIM

To review data on the impact of the COVID-19 pandemic on interventional radiology (IR) services.

MATERIALS AND METHODS

A systematic review of the available studies was performed according to the PRISMA guidelines.

RESULTS

A total of 14 studies met the inclusion criteria. IR caseload reduced between 16.8-80%, with elective activity affected more than emergency work. Trainees also experienced a 11-51.9% reduction in case volumes and many were redeployed to critical care. IR departments re-organised operations and personnel, and many continued to offer 24/7 services and support critical care areas through redeployment of staff. The majority of studies report no significant issues with the availability of personal protective equipment and that local or national governing body or radiology society guidelines were followed.

CONCLUSION

The COVID-19 pandemic reduced case volumes and training opportunities. IR departments showed flexibility in service delivery. The lessons learned offer novel insights into how services and training can be reorganised to ensure that IR continues to thrive.

Performance of near-infrared spectroscopy in pork shoulder as a predictor for pork belly softness

Pork belly quality indicators are economically relevant in the pork industry. Near-infrared (NIR) spectroscopy of the pork shoulder outer subcutaneous fat layer, belly flop angle, and subjective softness scores of the pork belly were measured (N = 144) to determine the accuracy of pork shoulder NIR spectroscopy as a predictor of pork belly softness. The NIR spectra hot carcass estimates explained over 80.0% variability in pork belly softness (80.5%–90.8%), with low prediction error, suggesting that NIR spectroscopy measured in the pork shoulder is an efficient and accurate indicator of pork belly softness to classify pork bellies for specific market demands.

Cancer blues? A promising judgment bias task indicates pessimism in nude mice with tumors

In humans, affective states can bias responses to ambiguous information: a phenomenon termed judgment bias (JB). Judgment biases have great potential for assessing affective states in animals, in both animal welfare and biomedical research. New animal JB tasks require construct validation, but for laboratory mice (Mus musculus), the most common research vertebrate, a valid JB task has proved elusive. Here (Experiment 1), we demonstrate construct validity for a novel mouse JB test: an olfactory Go/Go task in which subjects dig for high- or low-value food rewards. In C57BL/6 and Balb/c mice faced with ambiguous cues, latencies to dig were sensitive to high/low welfare housing: environmentally-enriched animals responded with relative 'optimism' through shorter latencies. Illustrating the versatility of this validated JB task across different fields of research, it further allowed us to test hypotheses about the mood-altering effects of cancer in male and female nude mice (Experiment 2). Males, although not females, treated ambiguous cues as intermediate; and males bearing subcutaneous lung adenocarcinomas also responded more pessimistically to these than did healthy controls. To our knowledge, this is the first evidence of a valid mouse JB task, and the first demonstration of pessimism in tumor-bearing animals. This task still needs to be refined to improve its sensitivity. However, it has great potential for investigating mouse welfare, the links between affective state and disease, depression-like states in animals, and hypotheses regarding the neurobiological mechanisms that underlie affect-mediated biases in judgment.

Predicting Postoperative Outcomes in Brain Tumor Patients With a 5-Factor Modified Frailty Index

BACKGROUND

Frailty indices may represent useful decision support tools to optimize modifiable drivers of quality and cost in neurosurgical care. However, classic indices are cumbersome to calculate and frequently require unavailable data. Recently, a more lean 5-factor modified frailty index (mFI-5) was introduced, but it has not yet been rigorously applied to brain tumor patients.

OBJECTIVE

To investigate the predictive value of the mFI-5 on length of stay (LOS), complications, and charges in surgical brain tumor patients.

METHODS

We retrospectively reviewed data for brain tumor patients who underwent primary surgery from 2017 to 2018. Bivariate (ANOVA) and multivariate (logistic and linear regression) analyses assessed the predictive power of the mFI-5 on postoperative outcomes.

RESULTS

Our cohort included 1692 patients with a mean age of 55.5 yr and mFI-5 of 0.80. Mean intensive care unit (ICU) and total LOS were 1.69 and 5.24 d, respectively. Mean pulmonary embolism (PE)/deep vein thrombosis (DVT), physiological/metabolic derangement, respiratory failure, and sepsis rates were 7.2%, 1.1%, 1.6%, and 1.7%, respectively. Mean total charges were $42 331. On multivariate analysis, each additional point on the mFI-5 was associated with a 0.32- and 1.38-d increase in ICU and total LOS, respectively; increased odds of PE/DVT (odds ratio (OR): 1.50), physiological/metabolic derangement (OR: 3.66), respiratory failure (OR: 1.55), and sepsis (OR: 2.12); and an increase in total charges of $5846.

CONCLUSION

The mFI-5 is a pragmatic and actionable tool which predicts LOS, complications, and charges in brain tumor patients. It may guide future efforts to risk-stratify patients with subsequent impact on postoperative outcomes.

The strain-7 study: multimodal, multivendor, multifield strength, scan:rescan comparison of global longitudinal and circumferential strain in healthy volunteers

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Insitute for Health Research

Background

There is clinical and prognostic evidence for global longitudinal strain (GLS) and circumferential strain (GCS). A range of techniques exist: 2-dimensional echocardiography (2Decho), 3-dimensional echocardiography (3Decho) and Cardiovascular Magnetic Resonance (CMR).

Purpose

To investigate inter-study repeatability and inter-method comparison of GLS and GCS techniques.

Methods

Volunteers underwent same day scan

rescan 2Decho, 3Decho, 1.5T Siemens CMR (Cine imaging and Displacement encoding with stimulated echoes [DENSE]), 3T Siemens CMR (Cine Imaging and DENSE) and 3T Philips CMR (Tagging and Fast strain-encoding [fSENC]) imaging. Strain was quantified for 2Decho (EchoPAC), 3Decho (TomTec), Feature tracking (FT) for cine imaging (CircleCVI), CIM (University of Auckland) for DENSE and Tag, and Myostrain (Myocardial solutions) for fSENC.

Results

20(6F) volunteers, mean age 33 ± 7 years, mean LVEF 62 ± 4%. All GLS and GCS methods had excellent inter-study agreement (ICC &gt; 0.75) with coefficient of variation (CoV) between 4-8% (Table 1). Median and IQR are presented in Figure 1.

Friedman’s test revealed statistically significant inter-method differences for GLS (χ2 = 66.4,p &lt; 0.0001) and GCS (χ2 = 50.9,p &lt; 0.0001). Post hoc analysis using Dunn’s test with Bonferroni correction demonstrated significant differences:

-GLS: 2Decho vs DENSE 1.5T (p = 0.001) and Myostrain 3T (p = 0.0116); 3Decho vs FT 3T (p = 0.049) and DENSE 1.5T (p &lt; 0.0001); FT 1.5T vs DENSE 1.5T (p = 0.001) and Myostrain 3T (p = 0.01); FT 3T vs Myostrain 3T (p &lt; 0.0001); DENSE 1.5T vs Tag 3T (p = 0.0008) and Myostrain 3T (p &lt; 0.0001); Tag 3T vs Myostrain (p = 0.02).

-GCS: 3Decho vs DENSE 1.5T (P = 0.0005), FT 1.5T (p &lt; 0.001), FT 3T (P &lt; 0.001) and Myostrain (p = 0.003); FT 1.5T vs Tag 3T (p = 0.001), FT 3T vs Myostrain 3T (p = 0.04).

Conclusion

There is excellent interstudy agreement for GLS and GCS methods. However, there are important inter-method differences in absolute values, that need to be considered for clinical application as a surveillance method and longitudinal studies.

Table 1 Acquisiton Post processing GLS CoV(%) GLS ICC GCS CoV(%) GCS ICC 2DEcho EchoPAC 4.88 0.80 - - 3DEcho TomTec 4.77 0.86 3.97 0.85 Siemens 1.5T cine FT CircleCVI 8.30 0.79 6.00 0.85 Siemens 3T cine FT CircleCVI 6.21 0.89 4.76 0.94 Philips 3T Tag CIM 6.15 0.89 5.86 0.88 Siemens 1.5T DENSE CIM 4.36 0.90 4.65 0.89 Philips 3T fSENC Myostrain 8.45 0.81 4.06 0.90 Interstudy agreement for the different GLS and GCS methods. Abstract Figure 1

Left ventricular ejection fraction as an imaging biomarker to guide cardiac resynchronisation therapy in heart failure patients: a multimodal comparison of 2D and 3D echocardiography and CMR

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The authors acknowledge financial support from the Department of Health through the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust and by the NIHR MedTech Co-operative for Cardiovascular Disease at Guy’s and St Thomas’ NHS Foundation Trust. This work was supported by the Wellcome/EPSRC Centre for Medical Engineering [WT 203148/Z/16/Z]. MSN was funded by a clinical lectureship awarded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the DoH, EPSRC, MRC or the Wellcome Trust.

Introduction – Imaging derived left ventricular ejection fraction (LVEF) has an important role to guide initiation of medical therapy and device insertion in patients with heart failure and reduced ejection fraction (HFrEF). Previous studies have reported the correlation and agreement of LVEF in various patient populations, but sparse evidence exists on patients with heart failure referred for Cardiac Resynchronisation Therapy (CRT) using 2D and 3D echocardiography (2DE & 3DE) and cardiovascular magnetic resonance (CMR).

Objectives – To determine the correlation and agreement of LVEF as determined by 2DE, 3DE and CMR in a cohort of HF patients referred for assessment of CRT.

Methods – Patients with suspected HFrEF referred for assessment for CRT therapy were included in this single centre study. Patients underwent 2DE, 3DE and CMR to derive LVEF, LVESV and LVEDV. Correlation was determined with Pearson’s correlation, agreement with Bland-Altman analysis and Cohen’s kappa analysis for agreement using a dichotomous cut off of LVEF ≤35% as a threshold for CRT insertion (Ponikowski, 2016).

Results - 55 patients (mean age 71 ± 9.2, 76% male) were included. The mean LVEF for 2DE, 3DE, CMR and were 32.4 ± 8.6, 32.1 ± 9.6 and 30.3 ± 9.5 respectively. CMR had a significantly lower LVEF compared to 2DE (p = 0.03).

There was good correlation between 3DE & CMR and 2DE & CMR, and excellent correlation between 3DE and 2DE for LVEF (Table 1). There was for trend for CMR to underestimate LVEF compared to 2DE and 3DE, with small biases although wide limits of agreement (Figure 1). There was excellent correlation of LVEDV and LVESV across all 3 techniques. CMR underestimated volumes compared to 2DE and 3DE with large biases and wide LOA.

The kappa coefficient agreement at threshold level for CRT insertion (LVEF ≤35%) was fair for 3DE and CMR (0.379, p = 0.004) and 2DE and CMR (0.462, p = 0.001), and moderate for 3DE and 2DE (0.575, p ≤ 0.001).

Conclusion – Whilst LVEF is not the only indicator to guide CRT insertion, it remains an important imaging parameter for clinical decision making. We observed large biases in left ventricular volumes between 2D, 3D and CMR. However, whilst the overall bias in LVEF is small, the wide limits of agreement (LOA) observed may represent an area of clinical uncertainty, which may impact on the dichotomous imaging threshold for CRT insertion.

Comparison of indices between modalities LVEF Correlation (r) LVEF Bias & LOA (%±SD) EDV Correlation (r) EDV Bias & LOA (mL ± SD) ESV Correlation (r) ESV Bias & LOA (mL ± SD) 3DE vs CMR 0.676 (p &lt; 0.001) +1.75 ± 15.4 0.896 (p &lt; 0.001) -82.16 ± 42.8 0.937 (p &lt; 0.001) -61.3 ± 34.9 3DE vs 2DE 0.872 (p &lt; 0.001) +0.48 ± 4.5 0.909 (p &lt; 0.001) -10.31 ± 28.3 0.936 (p &lt; 0.001) -8.42 ± 20.5 2DE vs CMR 0.675 (p &lt; 0.001) +2.35 ± 14.6 0.876 (p &lt; 0.001) -67.35 ± 36.3 0.898 (p &lt; 0.001) -51.42 ± 30.1 Abstract Figure. Bland-Altman Plot LVEF by 3DE & CMR

Predicting High-Value Care Outcomes After Surgery for Skull Base Meningiomas

BACKGROUND

Although various predictors of adverse postoperative outcomes among patients with meningioma have been established, research has yet to develop a method for consolidating these findings to allow for predictions of adverse health care outcomes for patients diagnosed with skull base meningiomas. The objective of the present study was to develop 3 predictive algorithms that can be used to estimate an individual patient's probability of extended length of stay (LOS) in hospital, experiencing a nonroutine discharge disposition, or incurring high hospital charges after surgical resection of a skull base meningioma.

METHODS

The present study used data from patients who underwent surgical resection for skull base meningiomas at a single academic institution between 2017 and 2019. Multivariate logistic regression analysis was used to predict extended LOS, nonroutine discharge, and high hospital charges, and 2000 bootstrapped samples were used to calculate an optimism-corrected C-statistic. The Hosmer-Lemeshow test was used to assess model calibration, and P < 0.05 was considered statistically significant.

RESULTS

A total of 245 patients were included in our analysis. Our cohort was mostly female (77.6%) and white (62.4%). Our models predicting extended LOS, nonroutine discharge, and high hospital charges had optimism-corrected C-statistics of 0.768, 0.784, and 0.783, respectively. All models showed adequate calibration (P>0.05), and were deployed via an open-access, online calculator: https://neurooncsurgery3.shinyapps.io/high_value_skull_base_calc/.

CONCLUSIONS

After external validation, our predictive models have the potential to aid clinicians in providing patients with individualized risk estimation for health care outcomes after meningioma surgery.

A quick assessment of reliable change in fatigue: Reliable change indices of the modified fatigue impact scale - 5 item (MFIS-5)

BACKGROUND

Reliably monitoring changes in fatigue is an ongoing concern.

OBJECTIVE

Evaluate reliable change using the Modified Fatigue Impact Scale 5-item version (MFIS-5) in people with MS (PwMS).

METHODS

The MFIS-5 was administered at three time points in 157 PwMS. Test-retest reliability and reliable change scores were calculated at the 0.70, 0.80, 0.90, and 0.95 confidence intervals.

RESULTS

Difference scores of 3, 4, 5, and 6 represent statistically meaningful change at the 0.70, 0.80, 0.90, and 0.95 confidence intervals, respectively.

CONCLUSION

Cut points derived from this study and prior work can help reliably assess changes in fatigue over time.

Effects of systematically varied thiourethane-functionalized filler concentration on polymerization behavior and relevant clinical properties of dental composites

Introduction of thiourethane (TU) oligomer to resin-based dental restorative materials reduces stress and improves fracture toughness without compromising conversion. Localization of TU at the resin-filler interface via silanization procedures may lead to more substantial stress reduction and clinical property enhancements. The objective of this study was to evaluate composite properties as a function of TU-functionalized filler concentration. TU oligomers were synthesized using click-chemistry techniques and subsequently silanized to barium glass filler. Resin-based composites were formulated using varying ratios of TU-functionalized filler and conventional methacrylate-silanized barium filler. Material property testing included thermogravimetric analysis, real-time polymerization kinetics and depth of cure, polymerization stress, stress relaxation and fracture toughness. Clinical property testing included water sorption/solubility, composite paste viscosity, and gloss and surface roughness measured before and after subjecting the samples to 6 h of continuous tooth brushing in a custom-built apparatus using a toothpaste/water mixture. Increasing TU-filler in the composite resulted in as much as a 78% reduction in stress, coupled with an increase in fracture toughness. Conversion was similar for all groups. After simulated tooth brushing, gloss reduction was lower for TU-containing composites and surface roughness was less than or equal to the control.

TROPHY registry - status report

INTRODUCTION

The TROPHY registry has been established to conduct an international multicenter prospective data collection on the surgical management of neonatal intraventricular hemorrhage (IVH)-related hydrocephalus to possibly contribute to future guidelines. The registry allows comparing the techniques established to treat hydrocephalus, such as external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). This first status report of the registry presents the results of the standard of care survey of participating centers assessed upon online registration.

METHODS

On the standard of treatment forms, each center indicated the institutional protocol of interventions performed for neonatal post-hemorrhagic hydrocephalus (nPHH) for a time period of 2 years (Y1 and Y2) before starting the active participation in the registry. In addition, the amount of patients enrolled so far and allocated to a treatment approach are reported.

RESULTS

According to the standard of treatment forms completed by 56 registered centers, fewer EVDs (Y1 55% Y2 46%) were used while more centers have implemented NEL (Y1 39%; Y2 52%) to treat nPHH. VAD (Y1 66%; Y2 66%) and VSGS (Y1 42%; Y2 41%) were used at a consistent rate during the 2 years. The majority of the centers used at least two different techniques to treat nPHH (43%), while 27% used only one technique, 21% used three, and 7% used even four different techniques. Patient data of 110 infants treated surgically between 9/2018 and 2/2021 (13% EVD, 15% VAD, 30% VSGS, and 43% NEL) were contributed by 29 centers.

CONCLUSIONS

Our results emphasize the varying strategies used for the treatment of nPHH. The international TROPHY registry has entered into a phase of growing patient recruitment. Further evaluation will be performed and published according to the registry protocol.

Identification of functional candidate variants and genes for feed efficiency in Holstein and Jersey cattle breeds using RNA-sequencing

The identification of functional genetic variants and associated candidate genes linked to feed efficiency may help improve selection for feed efficiency in dairy cattle, providing economic and environmental benefits for the dairy industry. This study used RNA-sequencing data obtained from liver tissue from 9 Holstein cows [n = 5 low residual feed intake (RFI), n = 4 high RFI] and 10 Jersey cows (n = 5 low RFI, n = 5 high RFI), which were selected from a single population of 200 animals. Using RNA-sequencing, 3 analyses were performed to identify: (1) variants within low or high RFI Holstein cattle; (2) variants within low or high RFI Jersey cattle; and (3) variants within low or high RFI groups, which are common across both Holstein and Jersey cattle breeds. From each analysis, all variants were filtered for moderate, modifier, or high functional effect, and co-localized quantitative trait loci (QTL) classes, enriched biological processes, and co-localized genes related to these variants, were identified. The overlapping of the resulting genes co-localized with functional SNP from each analysis in both breeds for low or high RFI groups were compared. For the first two analyses, the total number of candidate genes associated with moderate, modifier, or high functional effect variants fixed within low or high RFI groups were 2,810 and 3,390 for Holstein and Jersey breeds, respectively. The major QTL classes co-localized with these variants included milk and reproduction QTL for the Holstein breed, and milk, production, and reproduction QTL for the Jersey breed. For the third analysis, the common variants across both Holstein and Jersey breeds, uniquely fixed within low or high RFI groups were identified, revealing a total of 86,209 and 111,126 functional variants in low and high RFI groups, respectively. Across all 3 analyses for low and high RFI cattle, 12 and 31 co-localized genes were overlapping, respectively. Among the overlapping genes across breeds, 9 were commonly detected in both the low and high RFI groups (INSRR, CSK, DYNC1H1, GAB1, KAT2B, RXRA, SHC1, TRRAP, PIK3CB), which are known to play a key role in the regulation of biological processes that have high metabolic demand and are related to cell growth and regeneration, metabolism, and immune function. The genes identified and their associated functional variants may serve as candidate genetic markers and can be implemented into breeding programs to help improve the selection for feed efficiency in dairy cattle.

Development and comparison of RNA-sequencing pipelines for more accurate SNP identification: practical example of functional SNP detection associated with feed efficiency in Nellore beef cattle

Background

Optimization of an RNA-Sequencing (RNA-Seq) pipeline is critical to maximize power and accuracy to identify genetic variants, including SNPs, which may serve as genetic markers to select for feed efficiency, leading to economic benefits for beef production. This study used RNA-Seq data (GEO Accession ID: PRJEB7696 and PRJEB15314) from muscle and liver tissue, respectively, from 12 Nellore beef steers selected from 585 steers with residual feed intake measures (RFI; n = 6 low-RFI, n = 6 high-RFI). Three RNA-Seq pipelines were compared including multi-sample calling from i) non-merged samples; ii) merged samples by RFI group, iii) merged samples by RFI and tissue group. The RNA-Seq reads were aligned against the UMD3.1 bovine reference genome (release 94) assembly using STAR aligner. Variants were called using BCFtools and variant effect prediction (VeP) and functional annotation (ToppGene) analyses were performed.

Results

On average, total reads detected for Approach i) non-merged samples for liver and muscle, were 18,362,086.3 and 35,645,898.7, respectively. For Approach ii), merging samples by RFI group, total reads detected for each merged group was 162,030,705, and for Approach iii), merging samples by RFI group and tissues, was 324,061,410, revealing the highest read depth for Approach iii). Additionally, Approach iii) merging samples by RFI group and tissues, revealed the highest read depth per variant coverage (572.59 ± 3993.11) and encompassed the majority of localized positional genes detected by each approach. This suggests Approach iii) had optimized detection power, read depth, and accuracy of SNP calling, therefore increasing confidence of variant detection and reducing false positive detection. Approach iii) was then used to detect unique SNPs fixed within low- (12,145) and high-RFI (14,663) groups. Functional annotation of SNPs revealed positional candidate genes, for each RFI group (2886 for low-RFI, 3075 for high-RFI), which were significantly (P < 0.05) associated with immune and metabolic pathways.

Conclusion

The most optimized RNA-Seq pipeline allowed for more accurate identification of SNPs, associated positional candidate genes, and significantly associated metabolic pathways in muscle and liver tissues, providing insight on the underlying genetic architecture of feed efficiency in beef cattle.

Burnout and career satisfaction among attending neurosurgeons during the COVID-19 pandemic

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Burnout among attending neurosurgeons is associated with factors related to uncertainty and workflow changes during the COVID-19 pandemic.

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Career satisfaction is associated with cerebrovascular subspecialty training and willingness to pursue neurosurgery again if given the choice.

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Support for attending neurosurgeons is recommended during the transition to caring for patients in the COVID-19 era.

Objective

The novel coronavirus SARS-CoV-2 (COVID-19) pandemic has posed significant changes to physician workflow and healthcare delivery. This national survey investigated the impact of the pandemic on burnout and career satisfaction among U.S. attending neurosurgeons.

Methods

A 24-question survey was sent electronically to all American Association of Neurological Surgeons (AANS) attending members. The abbreviated Maslach Burnout Inventory (aMBI) was used to measure the following burnout and career satisfaction indices: emotional exhaustion, depersonalization, and personal accomplishment. Bivariate analyses were conducted and multivariate analyses were performed using logistic regression models.

Results

407 attending neurosurgeons were included in the present study, with an overall response rate of 17.7 %. The majority of respondents were male (88.7 %), White (84.3 %), and in practice for 15 years or more (64.6 %). The majority reported a decrease in work hours due to the pandemic (82.6 %), uncertainty about future earnings (80.3 %), and uncertainty regarding future healthcare reform (84.5 %). Burnout was identified in 83 (20.4 %) respondents, whereas career satisfaction was identified in 316 (77.6 %) respondents. Rate of burnout was decreased when compared to rates reported in the pre-COVID era.

In multivariate analysis, burnout was associated with working in a hostile or difficult environment since the rise of COVID-19 (OR = 2.534, p = 0.008), not having children (OR = 3.294, p = 0.011), being in practice for 5−15 years (vs. < 5 years) (OR = 4.568, p = 0.014), spending increased time conducting non-neurosurgical medical care due to COVID-19 (OR = 2.362, p = 0.019), feeling uncertain about future earnings due to COVID-19 (OR = 4.031, p = 0.035), and choosing not to pursue or feeling uncertain about pursuing neurosurgery again if given the choice (OR = 7.492, p < 0.001). Career satisfaction was associated with cerebrovascular subspecialty training (OR = 2.614, p = 0.046) and a willingness to pursue neurosurgery again if given the choice (OR = 2.962, p < 0.001).

Conclusion

Factors related to the novel COVID-19 pandemic have contributed to changes in workflow among U.S. attending neurosurgeons. Despite these changes, we report decreased burnout and high career satisfaction among U.S. neurosurgeons. Understanding modifiable stressors among neurosurgeons during the pandemic may help to identify effective future interventions to mitigate burnout and improve career satisfaction.

A national survey on the impact of the COVID-19 pandemic upon burnout and career satisfaction among neurosurgery residents

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U.S. neurosurgery residents report moderate burnout during the COVID-19 pandemic.

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Neurosurgery residents report uncertainty about future healthcare reform & earnings.

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The COVID-19 pandemic may impair residents’ achievement of surgical milestones.

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Burnout is associated with altered rotation or vacation schedules and lower PGY.

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Career satisfaction is associated with delivery of neurosurgical patient care.

The coronavirus disease 2019 (COVID-19) pandemic has posed significant changes to resident education and workflow. However, the impact of the pandemic on U.S. neurosurgery residents has not been well characterized. We investigated the impact of the COVID-19 pandemic on U.S. neurosurgery resident workflow, burnout, and career satisfaction. In 2020, a survey evaluating factors related to career satisfaction and burnout was emailed to 1,374 American Association of Neurological Surgeons (AANS) residents. Bivariate and multivariate (logistic) analyses were performed to characterize predictors of burnout and career satisfaction. 167 survey responses were received, with a response rate (12.2%) comparable to that of similar studies. Exclusion of incomplete responses yielded 111 complete responses. Most respondents were male (65.8%) and White (75.7%). Residents reported fewer work hours (67.6%) and concern that COVID-19 would impair their achievement of surgical milestones (65.8%). Burnout was identified in 29 (26.1%) respondents and career satisfaction in 82 (73.9%) respondents. In multivariate analysis, burnout was significantly associated with alterations in elective rotation/vacation schedules (p = .013) and the decision to not pursue neurosurgery again if given the choice (p < .001). Higher post-graduate year was associated with less burnout (p = .011). Residents displayed greater career satisfaction when focusing their clinical work upon neurosurgical care (p = .065). Factors related to COVID-19 have contributed to workflow changes among U.S. neurosurgery residents. We report a moderate burnout rate and a paradoxically high career satisfaction rate among neurosurgery residents. Understanding modifiable stressors during the COVID-19 pandemic may help to formulate interventions to mitigate burnout and improve career satisfaction among residents.