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Cummins DD, Sandoval-Pistorius SS, Cernera S, Fernandez-Gajardo R, Hammer LH, Starr PA. Physiological effects of dual target DBS in an individual with Parkinson's disease and a sensing-enabled pulse generator. Parkinsonism Relat Disord 2024; 122:106089. [PMID: 38460490 DOI: 10.1016/j.parkreldis.2024.106089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024]
Abstract
INTRODUCTION Deep brain stimulation (DBS) of the subthalamic nucleus (STN) or globus pallidus (GP) is an established therapy for Parkinson's disease (PD). Novel DBS devices can record local field potential (LFP) physiomarkers from the STN or GP. While beta (13-30 Hz) and gamma (40-90 Hz) STN and GP LFP oscillations correlate with PD motor severity and with therapeutic effects of treatments, STN-GP interactions in electrophysiology in patients with PD are not well characterized. METHODS Simultaneous bilateral STN and GP LFPs were recorded in a patient with PD who received bilateral STN-DBS and GP-DBS. Power spectra in each target and STN-GP coherence were assessed in various ON- and OFF-levodopa and DBS states, both at rest and with voluntary movement. RESULTS OFF-levodopa and OFF-DBS, beta peaks were present at bilateral STN and GP, coincident with prominent STN-GP beta coherence. Levodopa and dual-target-DBS (simultaneous STN-DBS and GP-DBS) completely suppressed STN-GP coherence. Finely-tuned gamma (FTG) activity at half the stimulation frequency (62.5 Hz) was seen in the STN during GP-DBS at rest. To assess the effects of movement on FTG activity, we recorded LFPs during instructed movement. We observed FTG activity in bilateral GP and bilateral STN during contralateral body movements while on GP-DBS and ON-levodopa. No FTG was seen with STN-DBS or dual-target-DBS. CONCLUSION Dual-target-DBS and levodopa suppressed STN-GP coherence. FTG throughout the basal ganglia was induced by GP-DBS in the presence of levodopa and movement. This bilateral STN-FTG and GP-FTG corresponded with the least severe bradykinesia state, suggesting a pro-kinetic role for FTG.
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Affiliation(s)
- Daniel D Cummins
- School of Medicine, University of California San Francisco, 533 Parnassus Ave, San Francisco, CA, 94143, United States.
| | - Stephanie S Sandoval-Pistorius
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave, Rm M779, San Francisco, CA, 94143, United States
| | - Stephanie Cernera
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave, Rm M779, San Francisco, CA, 94143, United States
| | - Rodrigo Fernandez-Gajardo
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave, Rm M779, San Francisco, CA, 94143, United States
| | - Lauren H Hammer
- Department of Neurology, University of California San Francisco, 1651 4th Street, East Care Center, San Francisco, CA, 94143, United States
| | - Philip A Starr
- School of Medicine, University of California San Francisco, 533 Parnassus Ave, San Francisco, CA, 94143, United States; Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Ave, Rm M779, San Francisco, CA, 94143, United States
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Cummins DD, Caton MT, Hemphill K, Lamboy A, Tu-Chan A, Meisel K, Narsinh KH, Amans MR. Clinical evaluation of pulsatile tinnitus: history and physical examination techniques to predict vascular etiology. J Neurointerv Surg 2024; 16:516-521. [PMID: 37311640 PMCID: PMC10716354 DOI: 10.1136/jnis-2023-020440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Pulsatile tinnitus (PT) may be due to a spectrum of cerebrovascular etiologies, ranging from benign venous turbulence to life threatening dural arteriovenous fistulas. A focused clinical history and physical examination provide clues to the ultimate diagnosis; however, the predictive accuracy of these features in determining PT etiology remains uncertain. METHODS Patients with clinical PT evaluation and DSA were included. The final etiology of PT after DSA was categorized as shunting, venous, arterial, or non-vascular. Clinical variables were compared between etiologies using multivariate logistic regression, and performance at predicting PT etiology was determined by area under the receiver operating curve (AUROC). RESULTS 164 patients were included. On multivariate analysis, patient reported high pitch PT (relative risk (RR) 33.81; 95% CI 3.81 to 882.80) compared with exclusively low pitch PT and presence of a bruit on physical examination (9.95; 2.04 to 62.08; P=0.007) were associated with shunting PT. Hearing loss was associated with a lower risk of shunting PT (0.16; 0.03 to 0.79; P=0.029). Alleviation of PT with ipsilateral lateral neck pressure was associated with a higher risk of venous PT (5.24; 1.62 to 21.01; P=0.010). An AUROC of 0.882 was achieved for predicting the presence or absence of a shunt and 0.751 for venous PT. CONCLUSION In patients with PT, clinical history and physical examination can achieve high performance at detecting a shunting lesion. Potentially treatable venous etiologies may also be suggested by relief with neck compression.
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Affiliation(s)
- Daniel D Cummins
- Departments of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Kafi Hemphill
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Allison Lamboy
- Departments of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adelyn Tu-Chan
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Karl Meisel
- McClaren Northern Michigan, Petoskey, Michigan, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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Andrews JP, Cummins DD, Morshed RA, Kinde B, Aghi MK, McDermott MW, Berger MS, Theodosopoulos PV. Intraventricular meningioma resection and visual outcomes. J Neurosurg 2024; 140:1001-1007. [PMID: 37877997 DOI: 10.3171/2023.7.jns23680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/20/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Intraventricular meningiomas (IVMs) of the lateral ventricle are rare tumors that present surgical challenges because of their deep location. Visual field deficits (VFDs) are one risk associated with these tumors and their treatment. VFDs may be present preoperatively due to the tumor and mass effect (tumor VFDs) or may develop postoperatively due to the surgical approach (surgical VFDs). This institutional series aimed to review surgical outcomes following resection of IVMs, with a focus on VFDs. METHODS Patients who received IVM resection at one academic institution between the years 1996 and 2021 were retrospectively reviewed. Diffusion tensor imaging (DTI) reconstructions of the optic radiations around the tumor were performed from preoperative IVM imaging. The VFD course and resolution were documented. RESULTS Thirty-two adult patients underwent IVM resection, with gross-total resection in 30 patients (93.8%). Preoperatively, tumor VFDs were present in 6 patients, resolving after surgery in 5 patients. Five other patients (without preoperative VFD) had new persistent surgical VFDs postoperatively (5/32, 15.6%) that persisted to the most recent follow-up. Of the 5 patients with persistent surgical VFDs, 4 received a transtemporal approach and 1 received a transparietal approach, and all these deficits occurred prior to regular use of DTI in preoperative imaging. CONCLUSIONS New surgical VFDs are a common neurological deficit after IVM resection. Preoperative DTI may demonstrate distortion of the optic radiations around the tumor, thus revealing safe operative corridors to prevent surgical VFDs.
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Affiliation(s)
| | | | | | - Benyam Kinde
- 2Ophthalmology, University of California, San Francisco, California
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Morshed RA, Cummins DD, Clark JP, Young JS, Haddad AF, Gogos AJ, Hervey-Jumper SL, Berger MS. Asleep triple-modality motor mapping for perirolandic gliomas: an update on outcomes. J Neurosurg 2024; 140:1029-1037. [PMID: 37856395 DOI: 10.3171/2023.8.jns231036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 08/08/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Maximal safe resection of gliomas near motor pathways is facilitated by intraoperative mapping. Here, the authors review their results with triple-modality asleep motor mapping with motor evoked potentials and bipolar and monopolar stimulation for cortical and subcortical mapping during glioma surgery in an expanded cohort. METHODS This was a retrospective analysis of patients who underwent resection of a perirolandic glioma near motor pathways. Clinical and neuromonitoring data were extracted from the electronic medical records for review. All patients with new or worsened postoperative motor deficits were followed for at least 6 months. Regression analyses were performed to assess factors associated with a persistent motor deficit. RESULTS Between January 2018 and December 2021, 160 operations were performed in 151 patients with perirolandic glioma. Sixty-four patients (40%) had preoperative motor deficits, and the median extent of resection was 98%. Overall, patients in 38 cases (23.8%) had new or worse immediate postoperative deficits by discharge, and persistent deficits by 6 months were seen in 6 cases (3.8%), all in patients with high-grade gliomas. There were no new persistent deficits in low-grade glioma patients (0%). The risk factors for a persistent deficit included an insular tumor component (OR 8.6, p = 0.01), preoperative motor weakness (OR 8.1, p = 0.03), intraoperative motor evoked potential (MEP) changes (OR 36.5, p < 0.0001), and peri-resection cavity ischemia (OR 7.5, p = 0.04). Most persistent deficits were attributable to ischemic injury despite structural preservation of the descending motor tracts. For patients with persistent motor deficits, there were 3 cases (50%) in which a change in MEP was noted but subsequent subcortical monopolar stimulation still elicited a response in the corresponding muscle groups, suggesting axonal activation distal to a point of injury. CONCLUSIONS Asleep triple motor mapping results in a low rate of permanent deficits, especially for low-grade gliomas. Peri-resection cavity ischemia continues to be a significant risk factor for permanent deficit despite maintaining appropriate distance for subcortical tracts based on monopolar feedback.
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Affiliation(s)
- Ramin A Morshed
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Daniel D Cummins
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - John P Clark
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Jacob S Young
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Alexander F Haddad
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Andrew J Gogos
- 2Department of Neurosurgery, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Shawn L Hervey-Jumper
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Mitchel S Berger
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
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Kalagara R, Chennareddy S, Reford E, Bhimani AD, Cummins DD, Downes MH, Tosto JM, Bederson JB, Mocco J, Putrino D, Kellner CP, Panov F. Complications of Implanted Vagus Nerve Stimulation: A Systematic Review and Meta-analysis. Cerebrovasc Dis 2024:000536362. [PMID: 38471473 DOI: 10.1159/000536362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/13/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Vagus Nerve Stimulation (VNS) has emerged as a promising tool in ischemic stroke rehabilitation. However, there has been no systematic review summarizing its adverse effects, critical information for patients and providers when obtaining informed consent for this novel treatment. This systematic review and meta-analysis reports the adverse effects of VNS. METHODS A systematic review was performed in accordance with PRISMA guidelines to identify common complications after VNS therapy. The search was executed in: Cochrane Central Register of Controlled Trials, Embase, and Ovid MEDLINE. All prospective, randomized controlled trials using implanted VNS therapy in adult patients were eligible for inclusion. Case studies and studies lacking complete complication reports were excluded. Extracted data included technology name, location of implantation, follow-up duration, purpose of VNS, and adverse event rates. RESULTS After title-and-abstract screening of 4933 studies, 21 were selected for final inclusion. Across these studies, 1474 patients received VNS implantation. VNS was used as a potential therapy for epilepsy (9), depression (8), anxiety (1), ischemic stroke (1), chronic heart failure (1), and fibromyalgia (1). The 5 most common post-implant adverse events were voice alteration/hoarseness (n=671, 45.5%), paresthesia (n = 233, 15.8%), cough (n = 221, 15.0%), dyspnea (n = 211, 14.3%), and pain (n = 170, 11.5%). CONCLUSIONS Complications from VNS are mild and transient, with reduction in severity and number of adverse events with increasing follow-up time. In prior studies, VNS has served as treatment option in several instances of treatment-resistant conditions, such as epilepsy and psychiatric conditions, and its use in stroke recovery and rehabilitation should continue to be explored.
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Cummins DD, Kalagara R, Downes MH, Park HJ, Tosto-Mancuso J, Putrino D, Panov FE, Kellner CP. Vagus nerve stimulation for enhanced stroke recovery after intracerebral hemorrhage: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE23676. [PMID: 38467050 PMCID: PMC10936935 DOI: 10.3171/case23676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/18/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Randomized controlled trial (RCT) evidence has revealed the efficacy of vagus nerve stimulation (VNS) paired with rehabilitation therapy, over therapy alone, for upper-limb functional recovery after ischemic stroke. However, this technique has not yet been described for the recovery of chronic motor deficits after hemorrhagic stroke. OBSERVATIONS Three years after left putaminal intracerebral hemorrhagic stroke with chronic upper-limb functional deficits, a patient was treated with VNS for enhanced stroke recovery. VNS was paired with 6 weeks of in-clinic physical therapy, resulting in upper-limb functional improvement of 14 points on the Fugl-Meyer Assessment Upper Extremity (FMA-UE) index for stroke recovery (maximum score of 66 equating to normal function). This improvement was more than 1 standard deviation above the improvement documented in the first successful RCT of VNS paired with therapy for ischemic stroke (5.0 ± 4.4 improvement on FMA-UE). LESSONS VNS is a promising therapy for enhanced recovery after hemorrhagic stroke and may offer greater improvement in function compared to that after ischemic stroke. Improvement in function can occur years after the time of intracerebral hemorrhage.
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Affiliation(s)
| | | | | | | | - Jenna Tosto-Mancuso
- 3Rehabilitation and Human Performance, Mount Sinai Health System, New York, New York; and
| | - David Putrino
- 3Rehabilitation and Human Performance, Mount Sinai Health System, New York, New York; and
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Cummins DD, Clark AJ, Gupta MC, Theologis AA. Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion for correction of lumbosacral fractional curves in adult (thoraco)lumbar scoliosis: A systematic review. N Am Spine Soc J 2024; 17:100299. [PMID: 38193108 PMCID: PMC10772279 DOI: 10.1016/j.xnsj.2023.100299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024]
Abstract
Background Anterior lumbar interbody fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF) may be used to correct the lumbosacral fractional curve (LsFC) in de novo adult (thoraco) lumbar scoliosis. Yet, the relative benefits of ALIF and TLIF for LsFC correction remain largely undetermined. Purpose To compare the currently available data comparing radiographic correction of the LsFC provided by ALIF and TLIF of LsFC in adult (thoraco)lumbar scoliosis. Methods A systematic review was performed on original articles discussing fractional curve correction of lumbosacral spinal deformity (using search criteria: "lumbar" and "fractional curve"). Articles which discussed TLIF or ALIF for LsFC correction were presented and radiographic results for TLIF and ALIF were compared. Results Thirty-one articles were returned in the original search criteria, with 7 articles included in the systematic review criteria. All 7 articles presented radiographic results using TLIF for LsFC correction. Three of these articles also discussed results for patients whose LsFC were treated with ALIFs; 2 articles directly compared TLIF and ALIF for LsFC correction. Level III and level IV evidence indicated ALIF as advantageous for reducing the coronal Cobb angle of the LsFC. There were mixed results on relative efficacy of ALIF and TLIF in the LsFC for restoration of adequate global coronal alignment. Conclusions Limited level III and IV evidence suggests ALIF as advantageous for reducing the coronal Cobb angle of the LsFC in de novo adult (thoraco) lumbar scoliosis. Relative efficacy of ALIF and TLIF in the LsFC for restoration of global coronal alignment may be dictated by several factors, including directionality and magnitude of preoperative coronal deformity. Given the limited and low-quality evidence, additional research is warranted to determine the ideal interbody support strategies to address the LsFC in adult (thoraco) lumbar scoliosis.
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Affiliation(s)
- Daniel D. Cummins
- Department of Orthopaedic Surgery, University of California — San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143 United States
| | - Aaron J. Clark
- Department of Neurological Surgery, UCSF, 400 Parnassus Ave, Eighth Floor, San Francisco, CA 94143, United States
| | - Munish C. Gupta
- Department of Orthopaedic Surgery, Washington University, Campus Box 8233, 660 Euclid Avenue, Saint Louis, MO 63110, United States
| | - Alekos A. Theologis
- Department of Orthopaedic Surgery, University of California — San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143 United States
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Cummins DD, Bernabei JM, Wang DD. Focused Ultrasound for Treatment of Movement Disorders: A Review of Non-Food and Drug Administration Approved Indications. Stereotact Funct Neurosurg 2024; 102:93-108. [PMID: 38368868 DOI: 10.1159/000535621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/30/2023] [Indexed: 02/20/2024]
Abstract
INTRODUCTION MRI-guided focused ultrasound (FUS) is an incisionless thermo-ablative procedure that may be used to treat medication-refractory movement disorders, with a growing number of potential anatomic targets and clinical applications. As of this article's publication, the only US Food and Drug Administration (FDA)-approved uses of FUS for movement disorders are thalamotomy for essential tremor (ET) and tremor-dominant Parkinson's Disease (PD), and pallidotomy for other cardinal symptoms of PD. We present a state-of-the-art review on all non-FDA approved indications of FUS for movement disorders, beyond the most well-described indications of ET and PD. Our objective was to summarize the safety and efficacy of FUS in this setting and provide a roadmap for future directions of FUS for movement disorders. METHODS A state-of-the-art review was conducted on use of FUS for non-FDA approved movement disorders. All movement disorders excluding FDA-approved uses for ET and PD were included. RESULTS A total of 25 studies on 172 patients were included. In patients with tremor plus dystonia syndromes (n = 6), ventralis intermediate nucleus of the thalamus (VIM)-FUS gave >50% tremor reduction, with no improvement in dystonia and worsened dystonia in 2/6 patients. Ventral-oralis complex (VO)-FUS gave >50% improvement for focal hand dystonia (n = 6) and 100% return to musical performance in musician's dystonia (n = 6). In patients with multiple sclerosis (MS) and tremor (n = 3), improvement in tremor was seen in 2 patients with a favorable skull density ratio; no MS disease change was noted after VIM-FUS. In patients with tremor and comorbid ataxia syndromes (n = 3), none were found to have worsened ataxia after VIM-FUS; all had clinically significant tremor improvement. Subthalamic nucleus (STN)-FUS for PD (n = 49) gave approximately 50% improvement in PD motor symptoms, with dystonia and mild dyskinesias as possible adverse effects. Cerebellothalamic tract (CTT-FUS) for ET (n = 42) gave 55-90% tremor improvement, with gait dysfunction as a rare persistent adverse effect. Pallidothalamic tract (PTT-FUS) for PD (n = 50) gave approximately 50% improvement in motor symptoms, with mild speech dysfunction as a possible adverse effect. CONCLUSION VIM-FUS appeared safe and effective for heterogenous tremor etiologies, and VO-FUS appeared most effective for isolated segmental dystonia. STN-FUS was effective for PD symptom reduction; postoperative dystonia and mild on-medication dyskinesias required medical management. Tractography-based targeting with CTT-FUS for ET and PTT-FUS for PD demonstrated promising early results. Larger prospective trials with long-term follow-up are needed to the evaluate the safety and efficacy non-FDA approved indications for FUS.
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Affiliation(s)
- Daniel D Cummins
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - John M Bernabei
- Department of Neurological Surgery, UCSF, San Francisco, California, USA
| | - Doris D Wang
- Department of Neurological Surgery, UCSF, San Francisco, California, USA
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Morshed RA, Cummins DD, Nguyen MP, Saggi S, Vasudevan HN, Braunstein SE, Goldschmidt E, Chang EF, McDermott MW, Berger MS, Theodosopoulos PV, Daras M, Hervey-Jumper SL, Aghi MK. Genomic alterations associated with postoperative nodular leptomeningeal disease after resection of brain metastases. J Neurosurg 2024; 140:328-337. [PMID: 37548547 DOI: 10.3171/2023.5.jns23460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/30/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE The relationship between brain metastasis resection and risk of nodular leptomeningeal disease (nLMD) is unclear. This study examined genomic alterations found in brain metastases with the aim of identifying alterations associated with postoperative nLMD in the context of clinical and treatment factors. METHODS A retrospective, single-center study was conducted on patients who underwent resection of brain metastases between 2014 and 2022 and had clinical and genomic data available. Postoperative nLMD was the primary endpoint of interest. Targeted next-generation sequencing of > 500 oncogenes was performed in brain metastases. Cox proportional hazards analyses were performed to identify clinical features and genomic alterations associated with nLMD. RESULTS The cohort comprised 101 patients with tumors originating from multiple cancer types. There were 15 patients with nLMD (14.9% of the cohort) with a median time from surgery to nLMD diagnosis of 8.2 months. Two supervised machine learning algorithms consistently identified CDKN2A/B codeletion and ERBB2 amplification as the top predictors associated with postoperative nLMD across all cancer types. In a multivariate Cox proportional hazards analysis including clinical factors and genomic alterations observed in the cohort, tumor volume (× 10 cm3; HR 1.2, 95% CI 1.01-1.5; p = 0.04), CDKN2A/B codeletion (HR 5.3, 95% CI 1.7-16.9; p = 0.004), and ERBB2 amplification (HR 3.9, 95% CI 1.1-14.4; p = 0.04) were associated with a decreased time to postoperative nLMD. CONCLUSIONS In addition to increased resected tumor volume, ERBB2 amplification and CDKN2A/B deletion were independently associated with an increased risk of postoperative nLMD across multiple cancer types. Additional work is needed to determine if targeted therapy decreases this risk in the postoperative setting.
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Affiliation(s)
| | | | | | | | - Harish N Vasudevan
- Departments of1Neurological Surgery and
- 2Radiation Oncology, University of California, San Francisco, California; and
| | - Steve E Braunstein
- 2Radiation Oncology, University of California, San Francisco, California; and
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Uggerly ASV, Cummins DD, Nguyen MP, Saggi S, Aghi MK, Morshed RA. Correlation of Brain Metastasis Genomic Alterations with Preoperative Imaging Features. World Neurosurg 2024; 181:e475-e482. [PMID: 37879437 DOI: 10.1016/j.wneu.2023.10.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The aim of this study was to examine associations between genomic alterations in brain metastases and common preoperative imaging findings including overt intratumoral hemorrhage, cystic features, and edema. METHODS A single-center, retrospective study was performed including patients who underwent surgical resection of brain metastasis with available preoperative magnetic resonance imaging (MRI). Next-generation sequencing of more than 500 coding genes was performed on the resected brain metastases. Preoperative MRI was reviewed to identify the presence of intratumoral hemorrhage, cystic features, and edema in the resected brain metastasis. Genomic data were then correlated with the imaging features using univariate and multivariate nominal logistic regression analyses. RESULTS We included 144 brain metastases from 141 patients in the study cohort. Half (72) of the metastases had an intratumoral hemorrhage, 26 (18%) had cystic features, and 130 (90%) had edema. Mutations in TP53 were associated with a reduced risk of intratumoral hemorrhage (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.07-0.5, P < 0.001). Mutations in RB1 and CCND1 were associated with elevated risk of the metastasis having cystic features (OR 10.3, 95% CI 2.0-52.6, P = 0.005, OR 18.4, 95% CI 2.2-155.3, P = 0.008, respectively). PIK3CA mutations were associated with a reduced risk of peritumoral edema (OR 0.2, 95% CI 0.04-0.8, P = 0.03). CONCLUSIONS Several genomic alterations in brain metastases are associated with MRI features including hemorrhage, cystic features, and edema. These results provide insight into tumor biology and patients at risk of developing these imaging features.
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Affiliation(s)
- Amalie S V Uggerly
- Department of Neurosurgery, Odense University Hospital, Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, Odense C, Denmark; Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Daniel D Cummins
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Minh P Nguyen
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Satvir Saggi
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California, USA.
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Theologis AA, Cummins DD, Kato S, Lewis S, Shaffrey C, Lenke L, Berven SH. Activity and sports resumption after long segment fusions to the pelvis for adult spinal deformity: survey results of AO Spine members. Spine Deform 2023; 11:1485-1493. [PMID: 37462878 PMCID: PMC10587314 DOI: 10.1007/s43390-023-00734-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/04/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE To assess recommendations for when adult spinal deformity (ASD) patients may return to athletic activities after surgery. METHODS A web-based survey was administered to members of AO Spine. The survey consisted of surgeon demographic information and questions asking when a patient undergoing a long thoracolumbar fusion (> 5 levels) with pelvic fixation for ASD would be allowed to resume unrestricted range of motion (ROM), non-contact sports, and contact sports postoperatively. Ordinal logistic regression was used to determine predictors for time to resume each activity. RESULTS One hundred twenty four members' responses were included for analysis. The majority of respondents would allow unrestricted ROM within 3 months postop (< 3 months: 81% vs > 3 months: 19%]. For when to return to non-contact sports, the most common responses were "2-3 months" (26.6%), "3-4 months" (26.6%), and "6-12 months" (18.5%). For when to return to contact sports, the majority advised > 4 months postop [> 4 months: "4-6 months" (19.2%), "6-12 months" (28.0%), " > 12 months" (28.8%) versus < 4 months: "1-2 months" (4.0%), "2-3 months" (1.6%), "3-4 months" (8.8%)]. 8.8% responded they would "never" allow resumption of contact sports. CONCLUSION There was significant variation between surgeons' recommendations for resumption of unrestricted range of motion and sports following long fusion with pelvic fixation for ASD. An evidence-based approach to activity recommendations will require information on outcomes and complications.
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Affiliation(s)
- Alekos A Theologis
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA.
| | - Daniel D Cummins
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - So Kato
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Stephen Lewis
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON, Canada
| | | | - Lawrence Lenke
- Department of Orthopedic Surgery, The Spine Hospital, Columbia University Medical Center, New York, NY, USA
| | - Sigurd H Berven
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
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12
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Cummins DD, Caton MT, Hemphill K, Lamboy A, Tu-Chan A, Meisel K, Narsinh KH, Amans MR. Cerebrovascular pulsatile tinnitus: causes, treatments, and outcomes in 164 patients with neuroangiographic correlation. J Neurointerv Surg 2023; 15:1014-1020. [PMID: 36190940 DOI: 10.1136/jnis-2022-019259] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pulsatile tinnitus (PT) can cause significant detriment to quality of life and may herald a life-threatening condition. Endovascular evaluation is the gold standard for the definitive diagnosis of PT and facilitates treatment. However, no large study has determined the distribution of causes and treatment outcomes of PT evaluated endovascularly. METHODS Consecutive patients evaluated at a multidisciplinary PT clinic from a single academic center were retrospectively reviewed. Patients with a suspected cerebrovascular etiology of PT based on clinical and/or non-invasive imaging, who were evaluated by endovascular techniques (arteriography, venography, manometry, and/or balloon test occlusion), were included in analysis. Baseline clinical features and treatment results by final etiology of PT were compared. RESULTS Of 552 patients referred for PT evaluation, 164 patients (29.7%) who underwent endovascular evaluation of PT were included. Mean (±SD) age at first clinical evaluation was 54.3±14.1 years (range 25-89 years); 111 patients (67.7%) were female. PT causes were 75.6% vascular and 24.4% non-vascular. Arteriovenous shunting lesions caused 20.7% of cases, venous etiologies 48.2%, and arterial etiologies 6.7%. Of patients with a shunting lesion treated with endovascular embolization, 96.9% had lasting significant improvement or resolution in PT. Endovascular stenting for venous sinus stenosis gave 84.6% of patients lasting improvement or resolution in PT. Arterial and non-vascular PT had fewer patients treated endovascularly and less improvement in PT symptoms. CONCLUSION PT with a suspected vascular cause is most often attributable to venous etiologies. PT caused by arteriovenous shunting or venous sinus stenosis may be effectively treated endovascularly.
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Affiliation(s)
- Daniel D Cummins
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Kafi Hemphill
- Neurology, University of California San Francisco, San Francisco, California, USA
| | - Allison Lamboy
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Adelyn Tu-Chan
- Neurology, University of California San Francisco, San Francisco, California, USA
| | - Karl Meisel
- Neurology, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
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13
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Sing D, Cummins DD, Burch S, Theologis AA. Computer-assisted Navigation in Lumbar Spine Instrumented Fusions: Comparison of In-hospital and 30-Day Postoperative Complications With Nonnavigated Fusions in a National Database. J Am Acad Orthop Surg 2023; 31:e638-e644. [PMID: 37130368 DOI: 10.5435/jaaos-d-22-01207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023] Open
Abstract
OBJECTIVE To compare in-hospital and 30-day postoperative complications for lumbar spine operations with and without use of computer-assisted navigation. METHODS Patients who underwent 1-level to 3-level lumbar spinal instrumentation and fusions 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Emergent procedures and patients aged younger than 18 years were excluded. Patients whose surgery involved the use of computer-assisted navigation were propensity score matched 1:4 based on preoperative demographics and comorbidities to operations without the use of navigation. Multivariate analysis was done to compare postoperative complications. RESULTS In total, 8,500 patients (average age: 60.7 ± 12.9, male 3,866, female 4,634) were analyzed (1,700 navigation, 6,800 Non-Navigated). Operations with navigation had significantly fewer overall complications (24% vs. 27%, P = 0.008; odds ratio [OR] = 0.83; CI = 0.73 to 0.95), fewer minor complications (20% vs. 24%, P = 0.002; OR = 0.80; CI = 0.70 to 0.91), fewer blood transfusions (17% v. 20%, P = 0.013; OR = 0.82; CI = 0.71 to 0.95), more wound dehiscences (0.4% vs. 0.8%, P = 0.022; OR = 2.16; CI = 1.12,4.19), and shorter average lengths of hospital stays (4.8 ± 4.8 vs. 5.1 ± 5.8 days, P = 0.01). Operations with computer navigation had significantly longer average surgical times (247 ± 129 vs 221 ± 115 minutes, P < 0.001). No significant differences were observed in 30-day revision rates, readmissions, and mortality. CONCLUSION Although use of computer-assisted navigation in short-segment lumbar spine fusions (1 to 3 levels) did not decrease revision rates for screw misplacement within 30 days postoperatively, it independently reduced the frequency of blood transfusions and minor complications and decreased hospital lengths of stay compared with operations without navigation. These benefits came at the expense of increased surgical times and wound dehiscences within 30 days postoperatively. Given the inherent limitations of large national databases, these results warrant confirmation through prospective, multicenter investigations.
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Affiliation(s)
- David Sing
- From the Department of Orthopaedic Surgery, University of California San Francisco (UCSF), San Francisco, CA
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14
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Cummins DD, Garcia JH, Nguyen MP, Saggi S, Chung JE, Goldschmidt E, Berger MS, Theodosopoulos PV, Chang EF, Daras M, Hervey-Jumper SL, Aghi MK, Morshed RA. Association of CDKN2A alterations with increased postoperative seizure risk after resection of brain metastases. Neurosurg Focus 2023; 55:E14. [PMID: 37527678 DOI: 10.3171/2023.5.focus23133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/16/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE Seizures are common and significantly disabling for patients with brain metastases (BMs). Although resection can provide seizure control, a subset of patients with BMs may continue to suffer seizures postoperatively. Genomic BM characteristics may influence which patients are at risk for postoperative seizures. This work explores correlations between genomic alterations and risk of postoperative seizures following BM resection. METHODS All patients underwent BM resection at a single institution, with available clinical and sequencing data on more than 500 oncogenes. Clinical seizures were documented pre- and postoperatively. A random forest machine learning classification was used to determine candidate genomic alterations associated with postoperative seizures, and clinical and top genomic variables were correlated with postoperative seizures by using Cox proportional hazards models. RESULTS There were 112 patients with BMs who underwent 114 surgeries and had at least 1 month of postoperative follow-up. Seizures occurred preoperatively in 26 (22.8%) patients and postoperatively in 25 (21.9%). The Engel classification achieved at 6 months for those with preoperative seizures was class I in 13 (50%); class II in 6 (23.1%); class III in 5 (19.2%), and class IV in 2 (7.7%). In those with postoperative seizures, only 8 (32.0%) had seizures preoperatively, and preoperative seizures were not a significant predictor of postoperative seizures (HR 1.84; 95% CI 0.79-4.37; p = 0.156). On random forest classification and multivariate Cox analysis controlling for factors including recurrence, extent of resection, and number of BMs, CDKN2A alterations were associated with postoperative seizures (HR 3.22; 95% CI 1.27-8.16; p = 0.014). Melanoma BMs were associated with higher risk of postoperative seizures compared with all other primary malignancies (HR 5.23; 95% CI 1.37-19.98; p = 0.016). Of 39 BMs with CDKN2A alteration, 35.9% (14/39) had postoperative seizures, compared to 14.7% (11/75) without CDKN2A alteration. The overall rate of postoperative seizures in melanoma BMs was 42.9% (15/35), compared with 12.7% (10/79) for all other primary malignancies. CONCLUSIONS CDKN2A alterations and melanoma primary malignancy are associated with increased postoperative seizure risk following resection of BMs. These results may help guide postoperative seizure prophylaxis in patients undergoing resection of BMs.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mariza Daras
- Departments of1Neurological Surgery and
- 2Neurology, University of California, San Francisco, California
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15
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Morshed RA, Saggi S, Cummins DD, Molinaro AM, Young JS, Viner JA, Villanueva-Meyer JE, Goldschmidt E, Boreta L, Braunstein SE, Chang EF, McDermott MW, Berger MS, Theodosopoulos PV, Hervey-Jumper SL, Aghi MK, Daras M. Identification of risk factors associated with leptomeningeal disease after resection of brain metastases. J Neurosurg 2023; 139:402-413. [PMID: 36640095 DOI: 10.3171/2022.12.jns221490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 12/07/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Resection of brain metastases (BMs) may be associated with increased risk of leptomeningeal disease (LMD). This study examined rates and predictors of LMD, including imaging subtypes, in patients who underwent resection of a BM followed by postoperative radiation. METHODS A retrospective, single-center study was conducted examining overall LMD, classic LMD (cLMD), and nodular LMD (nLMD) risk. Logistic regression, Cox proportional hazards, and random forest analyses were performed to identify risk factors associated with LMD. RESULTS Of the 217 patients in the cohort, 47 (21.7%) developed postoperative LMD, with 19 cases (8.8%) of cLMD and 28 cases (12.9%) of nLMD. Six-, 12-, and 24-month LMD-free survival rates were 92.3%, 85.6%, and 71.4%, respectively. Patients with cLMD had worse survival outcomes from the date of LMD diagnosis compared with nLMD (median 2.4 vs 6.9 months, p = 0.02, log-rank test). Cox proportional hazards analysis identified cerebellar/insular/occipital location (hazard ratio [HR] 3.25, 95% confidence interval [CI] 1.73-6.11, p = 0.0003), absence of extracranial disease (HR 2.49, 95% CI 1.27-4.88, p = 0.008), and ventricle contact (HR 2.82, 95% CI 1.5-5.3, p = 0.001) to be associated with postoperative LMD. A predictive model using random forest analysis with an area under the receiver operating characteristic curve of 0.87 in a test cohort identified tumor location, systemic disease status, and tumor volume as the most important factors associated with LMD. CONCLUSIONS Tumor location, absence of extracranial disease at the time of surgery, ventricle contact, and increased tumor volume were associated with LMD. Further work is needed to determine whether escalating therapies in patients at risk of LMD prevents disease dissemination.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lauren Boreta
- 3Radiation Oncology, University of California, San Francisco, California and
| | - Steve E Braunstein
- 3Radiation Oncology, University of California, San Francisco, California and
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16
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Uggerly ASV, Cummins DD, Nguyen MP, Saggi S, Goldschmidt E, Chang EF, McDermott MW, Berger MS, Theodosopoulos PV, Hervey-Jumper SL, Daras M, Aghi MK, Morshed RA. Genomic alterations associated with rapid progression of brain metastases. Neurosurg Focus 2023; 55:E15. [PMID: 37527682 DOI: 10.3171/2023.5.focus23214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/22/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE The aim of this study was to investigate associations between genomic alterations in resected brain metastases and rapid local and distant CNS recurrence identified at the time of postoperative adjuvant radiosurgery. METHODS This was a retrospective study on patients who underwent resection of intracranial brain metastases. Next-generation sequencing of more than 500 coding genes was performed on brain metastasis specimens. Postoperative and preradiosurgery MR images were compared to identify rapid recurrence. Genomic data were associated with rapid local and distant CNS recurrence of brain metastases using nominal regression analyses. RESULTS The cohort contained 92 patients with 92 brain metastases. Thirteen (14.1%) patients had a rapid local recurrence, and 64 (69.6%) patients had rapid distant CNS progression by the time of postoperative adjuvant radiosurgery, which occurred in a median time of 25 days (range 3-85 days) from surgery. RB1 and CTNNB1 mutations were seen in 8.7% and 9.8% of the cohort, respectively, and were associated with a significantly higher risk of rapid local recurrence (RB1: OR 13.6, 95% CI 2.0-92.39, p = 0.008; and CTNNB1: OR 11.97, 95% CI 2.25-63.78, p = 0.004) on multivariate analysis. No genes were found to be associated with rapid distant CNS progression. However, the presence of extracranial disease was significantly associated with a higher risk of rapid distant recurrence on multivariate analysis (OR 4.06, 95% CI 1.08-15.34, p = 0.039). CONCLUSIONS Genomic alterations in RB1 or CTNNB1 were associated with a significantly higher risk of rapid recurrence at the resection site. Although no genomic alterations were associated with rapid distant recurrence, having active extracranial disease was a risk factor for new lesions by the time of adjuvant radiotherapy after resection.
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Affiliation(s)
- Amalie S V Uggerly
- 1Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- 2Department of Clinical Research, University of Southern Denmark, Odense, Denmark; and
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Daniel D Cummins
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Minh P Nguyen
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Satvir Saggi
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Ezequiel Goldschmidt
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Edward F Chang
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Michael W McDermott
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Mitchel S Berger
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Philip V Theodosopoulos
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Shawn L Hervey-Jumper
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Mariza Daras
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Manish K Aghi
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Ramin A Morshed
- 3Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
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Arora A, Cummins DD, Wague A, Mendelis J, Samtani R, McNeill I, Theologis AA, Mummaneni PV, Berven S. Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review. Spine Deform 2023; 11:773-785. [PMID: 36811703 PMCID: PMC10261200 DOI: 10.1007/s43390-023-00654-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/21/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery. METHODS Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009). RESULTS Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization. CONCLUSIONS Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.
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Affiliation(s)
- Ayush Arora
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Daniel D Cummins
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Aboubacar Wague
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Joseph Mendelis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Rahul Samtani
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Ian McNeill
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University California, San Francisco, San Francisco, CA, USA
| | - Sigurd Berven
- Department of Orthopaedic Surgery, University of California - San Francisco UCSF, 500 Parnassus Ave, MUW320W, San Francisco, CA, 4143-0728, USA.
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Arora A, Demb J, Cummins DD, Callahan M, Clark AJ, Theologis AA. Predictive models to assess risk of extended length of stay in adults with spinal deformity and lumbar degenerative pathology: development and internal validation. Spine J 2023; 23:457-466. [PMID: 36892060 DOI: 10.1016/j.spinee.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/13/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND CONTEXT Postoperative recovery after adult spinal deformity (ASD) operations is arduous, fraught with complications, and often requires extended hospital stays. A need exists for a method to rapidly predict patients at risk for extended length of stay (eLOS) in the preoperative setting. PURPOSE To develop a machine learning model to preoperatively estimate the likelihood of eLOS following elective multi-level lumbar/thoracolumbar spinal instrumented fusions (≥3 segments) for ASD. STUDY DESIGN/SETTING Retrospectively from a state-level inpatient database hosted by the Health care cost and Utilization Project. PATIENT SAMPLE Of 8,866 patients of age ≥50 with ASD undergoing elective lumbar or thoracolumbar multilevel instrumented fusions. OUTCOME MEASURES The primary outcome was eLOS (>7 days). METHODS Predictive variables consisted of demographics, comorbidities, and operative information. Significant variables from univariate and multivariate analyses were used to develop a logistic regression-based predictive model that use six predictors. Model accuracy was assessed through area under the curve (AUC), sensitivity, and specificity. RESULTS Of 8,866 patients met inclusion criteria. A saturated logistic model with all significant variables from multivariate analysis was developed (AUC=0.77), followed by generation of a simplified logistic model through stepwise logistic regression (AUC=0.76). Peak AUC was reached with inclusion of six selected predictors (combined anterior and posterior approach, surgery to both lumbar and thoracic regions, ≥8 level fusion, malnutrition, congestive heart failure, and academic institution). A cutoff of 0.18 for eLOS yielded a sensitivity of 77% and specificity of 68%. CONCLUSIONS This predictive model can facilitate identification of adults at risk for eLOS following elective multilevel lumbar/thoracolumbar spinal instrumented fusions for ASD. With a fair diagnostic accuracy, the predictive calculator will ideally enable clinicians to improve preoperative planning, guide patient expectations, enable optimization of modifiable risk factors, facilitate appropriate discharge planning, stratify financial risk, and accurately identify patients who may represent high-cost outliers. Future prospective studies that validate this risk assessment tool on external datasets would be valuable.
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Affiliation(s)
- Ayush Arora
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Joshua Demb
- Division of Gastroenterology, Department of Medicine, University of California - San Diego, La Jolla, 9500 Gilman Drive, La Jolla, CA 92093, CA, USA
| | - Daniel D Cummins
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Matt Callahan
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, 400 Parnassus Ave, San Francisco, CA 94143, San Francisco, CA, USA
| | - Alekos A Theologis
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA.
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Morshed RA, Nguyen MP, Cummins DD, Saggi S, Young JS, Haddad AF, Goldschmidt E, Chang EF, McDermott MW, Berger MS, Theodosopoulos PV, Hervey-Jumper SL, Daras M, Aghi MK. CDKN2A/B co-deletion is associated with increased risk of local and distant intracranial recurrence after surgical resection of brain metastases. Neurooncol Adv 2023; 5:vdad007. [PMID: 36915611 PMCID: PMC10007908 DOI: 10.1093/noajnl/vdad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background While genetic alterations in brain metastases (BMs) have been previously explored, there are limited data examining their association with recurrence after surgical resection. This study aimed to identify genetic alterations within BMs associated with CNS recurrence after surgery across multiple cancer types. Methods A retrospective, single-center study was conducted with patients who underwent resection of a BM with available clinical and gene sequencing data available. Local and remote CNS recurrence were the primary study outcomes. Next-generation sequencing of the coding regions in over 500 oncogenes was performed in brain metastasis specimens. Cox proportional hazards analyses were performed to identify clinical features and genomic alterations associated with CNS recurrence. Results A total of 90 patients undergoing resection of 91 BMs composed the cohort. Genes most frequently mutated in the cohort included TP53 (64%), CDKN2A (37%), TERT (29%), CDKN2B (23%), NF1 (14%), KRAS (14%), and PTEN (13%), all of which occurred across multiple cancer types. CDKN2A/B co-deletion was seen in 21 (23.1%) brain metastases across multiple cancer types. In multivariate Cox proportional hazard analyses including patient, tumor, and treatment factors, CDKN2A/B co-deletion in the brain metastasis was associated with increased risk of local (HR 4.07, 95% CI 1.32-12.54, P = 0.014) and remote (HR 2.28, 95% CI 1.11-4.69, P = 0.025) CNS progression. Median survival and length of follow-up were not different based on CDKN2A/B mutation status. Conclusions CDKN2A/B co-deletion detected in BMs is associated with increased CNS recurrence after surgical resection. Additional work is needed to determine whether more aggressive treatment in patients with this mutation may improve outcomes.
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Affiliation(s)
- Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Minh P Nguyen
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel D Cummins
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Satvir Saggi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Jacob S Young
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Shawn L Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Mariza Daras
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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20
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Nguyen MP, Morshed RA, Dalle Ore CL, Cummins DD, Saggi S, Chen WC, Choudhury A, Ravi A, Raleigh DR, Magill ST, McDermott MW, Theodosopoulos PV. Supervised machine learning algorithms demonstrate proliferation index correlates with long-term recurrence after complete resection of WHO grade I meningioma. J Neurosurg 2023; 138:86-94. [PMID: 36303473 DOI: 10.3171/2022.4.jns212516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 04/25/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Meningiomas are the most common primary intracranial tumor, and resection is a mainstay of treatment. It is unclear what duration of imaging follow-up is reasonable for WHO grade I meningiomas undergoing complete resection. This study examined recurrence rates, timing of recurrence, and risk factors for recurrence in patients undergoing a complete resection (as defined by both postoperative MRI and intraoperative impression) of WHO grade I meningiomas. METHODS The authors conducted a retrospective, single-center study examining recurrence risk for adult patients with a single intracranial meningioma that underwent complete resection. Uni- and multivariate nominal logistic regression and Cox proportional hazards analyses were performed to identify variables associated with recurrence and time to recurrence. Two supervised machine learning algorithms were then implemented to confirm factors within the cohort that were associated with recurrence. RESULTS The cohort consisted of 823 patients who met inclusion criteria, and 56 patients (6.8%) had recurrence on imaging follow-up. The median age of the cohort was 56 years, and 77.4% of patients were female. The median duration of head imaging follow-up for the entire cohort was 2.7 years, but for the subgroup of patients who had a recurrence, the median follow-up was 10.1 years. Estimated 1-, 5-, 10-, and 15-year recurrence-free survival rates were 99.8% (95% confidence interval [CI] 98.8%-99.9%), 91.0% (95% CI 87.7%-93.6%), 83.6% (95% CI 78.6%-87.6%), and 77.3% (95% CI 69.7%-83.4%), respectively, for the entire cohort. On multivariate analysis, MIB-1 index (odds ratio [OR] per 1% increase: 1.34, 95% CI 1.13-1.58, p = 0.0003) and follow-up duration (OR per year: 1.12, 95% CI 1.03-1.21, p = 0.012) were both associated with recurrence. Gradient-boosted decision tree and random forest analyses both identified MIB-1 index as the main factor associated with recurrence, aside from length of imaging follow-up. For tumors with an MIB-1 index < 8, recurrences were documented up to 8 years after surgery. For tumors with an MIB-1 index ≥ 8, recurrences were documented up to 12 years following surgery. CONCLUSIONS Long-term imaging follow-up is important even after a complete resection of a meningioma. Higher MIB-1 labeling index is associated with greater risk of recurrence. Imaging screening for at least 8 years in patients with an MIB-1 index < 8 and at least 12 years for those with an MIB-1 index ≥ 8 may be needed to detect long-term recurrences.
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Affiliation(s)
- Minh P Nguyen
- 1Department of Neurological Surgery, University of California, San Francisco.,2School of Medicine, University of California, San Francisco
| | - Ramin A Morshed
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Cecilia L Dalle Ore
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Daniel D Cummins
- 1Department of Neurological Surgery, University of California, San Francisco.,2School of Medicine, University of California, San Francisco
| | - Satvir Saggi
- 1Department of Neurological Surgery, University of California, San Francisco.,2School of Medicine, University of California, San Francisco
| | - William C Chen
- 3Department of Radiation Oncology, University of California, San Francisco
| | - Abrar Choudhury
- 2School of Medicine, University of California, San Francisco
| | - Akshay Ravi
- 4Department of Hospital Medicine, University of California, San Francisco, California
| | - David R Raleigh
- 3Department of Radiation Oncology, University of California, San Francisco
| | - Stephen T Magill
- 5Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and
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21
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Cummins DD, Morshed RA, Goldschmidt E, Kuo YH. Comparison of shunt outcomes for non-bacterial infectious hydrocephalus with common hydrocephalus etiologies: a retrospective case-control study. World Neurosurg 2022; 164:e582-e589. [PMID: 35552038 DOI: 10.1016/j.wneu.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Shunting is an established treatment for hydrocephalus, yet reports on shunt outcomes for non-bacterial infectious (NBI) hydrocephalus are limited. Furthermore, comparison of mechanisms and rates of failure for shunted NBI hydrocephalus versus more typical etiologies remains undetermined. METHODS Patients who underwent shunting for hydrocephalus at two centers (1995-2020) were included. Indications for shunting were grouped as "typical" (congenital, post-hemorrhagic, normal pressure hydrocephalus, malignancy-related, trauma, and idiopathic) and NBI hydrocephalus (coccidioidomycosis, cryptococcus, and neurocysticercosis). Rates of shunt malfunction were compared. RESULTS There were 261 patients shunted for typical hydrocephalus (48.7% male; age 50.7±21.7) and 93 NBI hydrocephalus (72.0% male; age 41.8±13.2). For patients with typical hydrocephalus, 29.5% required ≥1 shunt revision, compared with 64.5% with NBI hydrocephalus (p<1E-5). Of those with malfunction, NBI shunts required more revision operations (median 3.0; max 21) compared with typical shunts (median 2.0; max 6; p<0.05). Censored median time to shunt failure for NBI hydrocephalus was 26.9 months and not reached for typical etiologies by 180 months. Multivariate analysis showed shunts for NBI hydrocephalus were significantly more likely to fail (HR 2.25; 95% CI 1.58-3.19). A distal pseudocyst was implicated in 30.0% and 2.6% of shunt failures for NBI and typical hydrocephalus, respectively (p<1E-5). Sixteen (26.7%) NBI shunt failures required revision to lower resistance systems compared to six (7.8%) typical failures (p<0.05). CONCLUSIONS Shunts placed for hydrocephalus secondary to non-bacterial infections are complicated by significantly higher rates of malfunction. These patients are prone to develop distal abdominal pseudocysts and often require revision to low-resistance systems.
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Affiliation(s)
- Daniel D Cummins
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Yu-Hung Kuo
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
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22
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Cummins DD, Morshed RA, Tihan T, Kunwar S. Calcifying pseudoneoplasm of the neuraxis within the sellar region: illustrative case. Journal of Neurosurgery: Case Lessons 2022; 3:CASE2286. [PMID: 36303491 PMCID: PMC9379716 DOI: 10.3171/case2286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are numerous atypical lesions of the sellar and suprasellar region that are often mistaken for pituitary adenomas. It is important to consider rare mimics of more common pathologies in this region. OBSERVATIONS The authors detail the case of a 37-year-old woman with hypopituitarism who was found to have an atypical sellar mass with slow growth on interval imaging. The lesion was debulked via a microscopic endonasal transsphenoidal approach and found to be a calcifying pseudoneoplasm of the neuraxis (CAPNON). LESSONS CAPNON is a rare disease entity that may affect the sellar region. CAPNON should be on the differential diagnosis for sellar masses that are associated with T1 and T2 hypointensity on magnetic resonance imaging with minimal enhancement. Although CAPNON is not at risk for malignant progression, these benign lesions can continue to grow after a subtotal resection and require follow-up.
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Affiliation(s)
| | | | - Tarik Tihan
- Pathology, University of California, San Francisco, San Francisco, California
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23
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Liu J, Kumar S, Hong J, Huang ZM, Paez D, Castillo M, Calvo M, Chang HW, Cummins DD, Chung M, Yeroushalmi S, Bartholomew E, Hakimi M, Ye CJ, Bhutani T, Matloubian M, Gensler LS, Liao W. Combined Single Cell Transcriptome and Surface Epitope Profiling Identifies Potential Biomarkers of Psoriatic Arthritis and Facilitates Diagnosis via Machine Learning. Front Immunol 2022; 13:835760. [PMID: 35309349 PMCID: PMC8924042 DOI: 10.3389/fimmu.2022.835760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
Early diagnosis of psoriatic arthritis (PSA) is important for successful therapeutic intervention but currently remains challenging due, in part, to the scarcity of non-invasive biomarkers. In this study, we performed single cell profiling of transcriptome and cell surface protein expression to compare the peripheral blood immunocyte populations of individuals with PSA, individuals with cutaneous psoriasis (PSO) alone, and healthy individuals. We identified genes and proteins differentially expressed between PSA, PSO, and healthy subjects across 30 immune cell types and observed that some cell types, as well as specific phenotypic subsets of cells, differed in abundance between these cohorts. Cell type-specific gene and protein expression differences between PSA, PSO, and healthy groups, along with 200 previously published genetic risk factors for PSA, were further used to perform machine learning classification, with the best models achieving AUROC ≥ 0.87 when either classifying subjects among the three groups or specifically distinguishing PSA from PSO. Our findings thus expand the repertoire of gene, protein, and cellular biomarkers relevant to PSA and demonstrate the utility of machine learning-based diagnostics for this disease.
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Affiliation(s)
- Jared Liu
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Sugandh Kumar
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Julie Hong
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Zhi-Ming Huang
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Diana Paez
- Division of Rheumatology, Department of Medicine, University of California at San Francisco, San Francisco, CA, United States
| | - Maria Castillo
- Division of Rheumatology, Department of Medicine, University of California at San Francisco, San Francisco, CA, United States
| | - Maria Calvo
- Division of Rheumatology, Department of Medicine, University of California at San Francisco, San Francisco, CA, United States
| | - Hsin-Wen Chang
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Daniel D. Cummins
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Mimi Chung
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Samuel Yeroushalmi
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Erin Bartholomew
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Marwa Hakimi
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Chun Jimmie Ye
- Division of Rheumatology, Department of Medicine, University of California at San Francisco, San Francisco, CA, United States
- Institute for Human Genetics, University of California at San Francisco, San Francisco, CA, United States
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, United States
- Institute of Computational Health Sciences, University of California at San Francisco, San Francisco, CA, United States
- Parker Institute for Cancer Immunotherapy, San Francisco, CA, United States
- Chan Zuckerberg Biohub, San Francisco, CA, United States
| | - Tina Bhutani
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
| | - Mehrdad Matloubian
- Division of Rheumatology, Department of Medicine, University of California at San Francisco, San Francisco, CA, United States
- Rosalind Russell/Ephraim P Engleman Rheumatology Research Center, University of California at San Francisco, San Francisco, CA, United States
| | - Lianne S. Gensler
- Division of Rheumatology, Department of Medicine, University of California at San Francisco, San Francisco, CA, United States
| | - Wilson Liao
- Department of Dermatology, University of California at San Francisco, San Francisco, CA, United States
- Institute for Human Genetics, University of California at San Francisco, San Francisco, CA, United States
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24
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Cummins DD, Caton MT, Shah V, Meisel K, Glastonbury C, Amans MR. MRI and MR angiography evaluation of pulsatile tinnitus: A focused, physiology-based protocol. J Neuroimaging 2022; 32:253-263. [PMID: 34910345 PMCID: PMC8917066 DOI: 10.1111/jon.12955] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Pulsatile tinnitus (PT) is the subjective sensation of a pulse-synchronous sound, most often due to a cerebrovascular etiology. PT can severely impact quality of life and may indicate a life-threatening process, yet a timely and accurate diagnosis can often lead to effective treatment. Clinical assessment with a history and physical examination can often suggest a diagnosis for PT, but is rarely definitive. Therefore, PT should be evaluated with a comprehensive and targeted radiographic imaging protocol. MR imaging provides a safe and effective means to evaluate PT. Specific MR sequences may be used to highlight different elements of cerebrovascular anatomy and physiology. However, routine MR evaluation of PT must comply with economic and practical constraints, while effectively capturing both common and rarer, life-threatening etiologies of PT. METHODS In this state-of-the-art review, we describe our institutional MR protocol for evaluating PT. RESULTS This protocol includes the following dedicated sequences: time-of-flight magnetic resonance angiography; arterial spin labeling; spoiled gradient recalled acquisition in the steady state; time-resolved imaging of contrast kinetics; diffusion weighted imaging, and 3-dimensional fluid-attenuated inversion recovery. CONCLUSIONS We describe the physiologic and clinical rationale for including each MR sequence in a comprehensive PT imaging protocol, and detail the role of MR within the broader evaluation of PT, from clinical presentation to treatment.
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Affiliation(s)
- Daniel D. Cummins
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Michael T. Caton
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Vinil Shah
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Karl Meisel
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Christine Glastonbury
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew R. Amans
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA,Corresponding author: Matthew R. Amans, Address: 505 Parnassus Ave, Room L349, San Francisco, CA 94143, Telephone: 415-353-1863, Fax: 415-353-8606,
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25
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Liu J, Chang HW, Grewal R, Cummins DD, Bui A, Beck KM, Sekhon S, Yan D, Huang ZM, Schmidt TH, Yang EJ, Sanchez IM, Nakamura M, Bhattarai S, Thibodeaux Q, Ahn R, Pauli M, Bhutani T, Rosenblum MD, Liao W. Transcriptomic Profiling of Plaque Psoriasis and Cutaneous T-Cell Subsets during Treatment with Secukinumab. JID Innov 2021; 2:100094. [PMID: 35757784 PMCID: PMC9214344 DOI: 10.1016/j.xjidi.2021.100094] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/03/2021] [Accepted: 07/29/2021] [Indexed: 01/01/2023] Open
Abstract
The IL-17A inhibitor secukinumab is efficacious for the treatment of psoriasis. To better understand its mechanism of action, we investigated its impact on psoriatic lesions from 15 patients with moderate-to-severe plaque psoriasis undergoing secukinumab treatment. We characterized the longitudinal transcriptomic changes of whole lesional skin tissue as well as cutaneous CD4+ and CD8+ T effector cells and CD4+ T regulatory cells across 12 weeks of treatment. Secukinumab was clinically effective and reduced disease-associated overexpression of IL17A , IL17F, IL23A, IL23R, and IFNG in whole tissue as soon as 2 weeks after initiation of treatment. IL17A overexpression in T-cell subsets, primarily CD8+ T cells, was also reduced. Although secukinumab treatment resolved 89‒97% of psoriasis-associated expression differences in bulk tissue and T-cell subsets by week 12 of treatment, we observed expression differences involved in IFN signaling and metallothionein synthesis that remained unresolved at this time point as well as potential treatment-associated expression differences involved in IL-15 signaling. These changes were accompanied by shifts in broader immune cell composition on the basis of deconvolution of RNA-sequencing data. In conclusion, our study reveals several phenotypic and cellular changes within the lesion that underlie clinical improvement from secukinumab.
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Affiliation(s)
- Jared Liu
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Hsin-Wen Chang
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Robby Grewal
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Daniel D. Cummins
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Audrey Bui
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Kristen M. Beck
- Department of Dermatology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sahil Sekhon
- Department of Dermatology, Howard University, Washington, District of Columbia, USA
| | - Di Yan
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, NYU Langone Health, New York, New York, USA
| | - Zhi-Ming Huang
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Timothy H. Schmidt
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Eric J. Yang
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Isabelle M. Sanchez
- Department of Dermatology, College of Medicine, University of Illinois, Chicago, Illinois, USA
| | - Mio Nakamura
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Shrishti Bhattarai
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Quinn Thibodeaux
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Richard Ahn
- Institute for Quantitative & Computational Biosciences, University of California Los Angeles, Los Angeles, California, USA
| | - Mariela Pauli
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Tina Bhutani
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Michael D. Rosenblum
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - Wilson Liao
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA,Correspondence: Wilson Liao, Department of Dermatology, University of California San Francisco, 2340 Sutter Street, Box 0808, San Francisco, California 94143, USA.
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Cummins DD, Morshed RA, Chavez MM, Avalos LN, Sudhakar V, Chung JE, Gallagher A, Saggi S, Daras M, Braunstein S, Theodosopoulos PV, McDermott MW, Aghi MK. Salvage Surgery for Local Control of Brain Metastases After Previous Stereotactic Radiosurgery: A Single-Center Series. World Neurosurg 2021; 158:e323-e333. [PMID: 34740830 DOI: 10.1016/j.wneu.2021.10.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although overall survival (OS) has improved in patients with brain metastases (BMs), control of recurrent BMs remains a therapeutic challenge. Salvage surgery may achieve acceptable control rates in the setting of progression after previous stereotactic radiosurgery (SRS), yet it remains a question how additional adjuvant therapies may affect outcomes and how patient selection for salvage surgery may be optimized. METHODS Patients receiving salvage surgery for BM progression after previous SRS were retrospectively reviewed from a single center. Outcomes of interest included local tumor progression, leptomeningeal dissemination, and OS. Cox proportional hazard models and nominal logistic regression were applied to determine factors associated with outcomes of interest. RESULTS A total of 43 patients with 50 BMs were included. After salvage surgery, local progression was observed for 17 BMs (34%), leptomeningeal dissemination was observed in 17 patients (39.5%), and censored median OS was 17.9 months. On multivariate analysis, use of brachytherapy was associated with improved local control (hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.04-0.6; P = 0.008). For patients treated with SRS ≥4.5 months before salvage surgery, both brachytherapy (HR, 0.07; 95% CI, 0.01-0.39; P = 0.002) and postoperative adjuvant SRS (HR, 0.14; 95% CI, 0.02-1.00; P = 0.05) were associated with improved local control compared with no adjuvant radiation therapy. Presence of extracranial malignancy (HR, 6.70; 95% CI, 2.58-17.42; P < 0.0001) was associated with shorter survival. Graded prognostic assessment underestimated survival in 79.1% of patients, with a mean difference of 18.9 months between graded prognostic assessment-estimated and actual OS. CONCLUSIONS In properly selected patients, salvage surgery may be an appropriate therapy for BM progression after previous SRS. Adjuvant brachytherapy and repeat SRS can offer significant benefit for local control with salvage resection.
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Affiliation(s)
- Daniel D Cummins
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ramin A Morshed
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
| | - Miguel M Chavez
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Lauro N Avalos
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Vivek Sudhakar
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason E Chung
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Aaron Gallagher
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Satvir Saggi
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Mariza Daras
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | | | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Cummins DD, Kochanski RB, Gilron R, Swann NC, Little S, Hammer LH, Starr PA. Chronic Sensing of Subthalamic Local Field Potentials: Comparison of First and Second Generation Implantable Bidirectional Systems Within a Single Subject. Front Neurosci 2021; 15:725797. [PMID: 34447294 PMCID: PMC8382799 DOI: 10.3389/fnins.2021.725797] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/16/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Many adaptative deep brain stimulation (DBS) paradigms rely upon the ability to sense neural signatures of specific clinical signs or symptoms in order to modulate therapeutic stimulation. In first-generation bidirectional neurostimulators, the ability to sense neural signals during active stimulation was often limited by artifact. Newer devices, with improved design specifications for sensing, have recently been developed and are now clinically available. OBJECTIVE To compare the sensing capabilities of the first-generation Medtronic PC + S and second-generation Percept PC neurostimulators within a single patient. METHODS A 42-year-old man with Parkinson's disease was initially implanted with left STN DBS leads connected to a PC + S implantable pulse generator. Four years later, the PC + S was replaced with the Percept PC. Local field potential (LFP) signals were recorded, both with stimulation OFF and ON, at multiple timepoints with each device and compared. Offline processing of time series data included artifact removal using digital filtering and template subtraction, before subsequent spectral analysis. With Percept PC, embedded processing of spectral power within a narrow frequency band was also utilized. RESULTS In the absence of stimulation, both devices demonstrated a peak in the beta range (approximately 20 Hz), which was stable throughout the 4-year period. Similar to previous reports, recordings with the PC + S during active stimulation demonstrated significant stimulation artifact, limiting the ability to recover meaningful LFP signal. In contrast, the Percept PC, using the same electrodes and stimulation settings, produced time series data during stimulation with spectral analysis revealing a peak in the beta-band. Online analysis by the Percept demonstrated a reduction in beta-band activity with increasing stimulation amplitude. CONCLUSION This report highlights recent advances in implantable neurostimulator technology for DBS, demonstrating improvements in sensing capabilities during active stimulation between first- and second-generation devices. The ability to reliably sense during stimulation is an important step toward both the clinical implementation of adaptive algorithms and the further investigation into the neurophysiology underlying movement disorders.
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Affiliation(s)
- Daniel D. Cummins
- School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Ryan B. Kochanski
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Roee Gilron
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Nicole C. Swann
- Department of Human Physiology, University of Oregon, Eugene, OR, United States
| | - Simon Little
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Lauren H. Hammer
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Philip A. Starr
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
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28
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Neumann WJ, Memarian Sorkhabi M, Benjaber M, Feldmann LK, Saryyeva A, Krauss JK, Contarino MF, Sieger T, Jech R, Tinkhauser G, Pollo C, Palmisano C, Isaias IU, Cummins DD, Little SJ, Starr PA, Kokkinos V, Gerd-Helge S, Herrington T, Brown P, Richardson RM, Kühn AA, Denison T. The sensitivity of ECG contamination to surgical implantation site in brain computer interfaces. Brain Stimul 2021; 14:1301-1306. [PMID: 34428554 PMCID: PMC8460992 DOI: 10.1016/j.brs.2021.08.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/05/2021] [Accepted: 08/19/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Brain sensing devices are approved today for Parkinson's, essential tremor, and epilepsy therapies. Clinical decisions for implants are often influenced by the premise that patients will benefit from using sensing technology. However, artifacts, such as ECG contamination, can render such treatments unreliable. Therefore, clinicians need to understand how surgical decisions may affect artifact probability. OBJECTIVES Investigate neural signal contamination with ECG activity in sensing enabled neurostimulation systems, and in particular clinical choices such as implant location that impact signal fidelity. METHODS Electric field modeling and empirical signals from 85 patients were used to investigate the relationship between implant location and ECG contamination. RESULTS The impact on neural recordings depends on the difference between ECG signal and noise floor of the electrophysiological recording. Empirically, we demonstrate that severe ECG contamination was more than 3.2x higher in left-sided subclavicular implants (48.3%), when compared to right-sided implants (15.3%). Cranial implants did not show ECG contamination. CONCLUSIONS Given the relative frequency of corrupted neural signals, we conclude that implant location will impact the ability of brain sensing devices to be used for "closed-loop" algorithms. Clinical adjustments such as implant location can significantly affect signal integrity and need consideration.
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Affiliation(s)
- Wolf-Julian Neumann
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Germany.
| | - Majid Memarian Sorkhabi
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Moaad Benjaber
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Lucia K Feldmann
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Assel Saryyeva
- Department of Neurosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Maria Fiorella Contarino
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Tomas Sieger
- Department of Neurology, Charles University, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Robert Jech
- Department of Neurology, Charles University, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Gerd Tinkhauser
- Department of Neurology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Claudio Pollo
- Department of Neurosurgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Chiara Palmisano
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Ioannis U Isaias
- Department of Neurology, University Hospital of Würzburg and Julius Maximilian University of Würzburg, Würzburg, Germany
| | - Daniel D Cummins
- Department of Neurology, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Simon J Little
- Department of Neurology, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Philip A Starr
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Vasileios Kokkinos
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Schneider Gerd-Helge
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Todd Herrington
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter Brown
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea A Kühn
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Timothy Denison
- MRC Brain Network Dynamics Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
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Ma H, Cummins DD, Edelstein NB, Gomez J, Khan A, Llewellyn MD, Picudella T, Willsey SR, Nangia S. Modeling Diversity in Structures of Bacterial Outer Membrane Lipids. J Chem Theory Comput 2017; 13:811-824. [DOI: 10.1021/acs.jctc.6b00856] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Huilin Ma
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Daniel D. Cummins
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Natalie Brooke Edelstein
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Jerry Gomez
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Aliza Khan
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Masud Dikita Llewellyn
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Tara Picudella
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Sarah Rose Willsey
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Shikha Nangia
- Department of Biomedical
and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
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30
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Abstract
Deontic reasoning is reasoning about what one may, ought, or ought not do in a given set of circumstances. Virtually all of our social institutions and child-rearing practices presume the capacity to reason about deontic concepts, such as what is permitted, obligated, or prohibited. Despite this, very little is known about the development of deontic reasoning. Two experiments were conducted that contrasted children's reasoning performance on deontic and indicative reasoning tasks (i.e., the reduced array selection version of the Wason card selection task). Like adults, children as young as 3 years of age were found to adopt a violation-detecting strategy more often when reasoning about the deontic case than when reasoning about the indicative case. These results indicate that violation detection emerges as an effective deontic reasoning very early in human development.
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Affiliation(s)
- D D Cummins
- Psychology Department, California State University, Sacramento 95819, USA.
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31
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Abstract
Evidence is presented that implicates two factors in deductive reasoning about causality. The factors are alternative causes and disabling conditions (factors that prevent effects from occurring in the presence of viable causes). A causal analysis is presented in which these factors impact on judgments concerning causal necessity and sufficiency, which in turn determine deductive entailment relations. In Experiment 1, these factors were found to impact causal deductive judgments more strongly than did logical form. In Experiment 2, causal deductive judgments were found to vary as a function of familiarity with a particular causal relationship: The more familiar the causal relationship, the less willing reasoners were to accept conclusions based on them.
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32
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Abstract
An experiment was conducted to investigate the relative contributions of syntactic form and content to conditional reasoning. The content domain chosen was that of causation. Conditional statements that described causal relationships (if mean value of cause, then mean value of effect) were embedded in simple arguments whose entailments are governed by the rules of truth-functional logic (i.e., modus ponens, modus tollens, denying the antecedent, and affirming the consequent). The causal statements differed in terms of the number of alternative causes and disabling conditions that characterized the causal relationship. (A disabling condition is an event that prevents an effect from occurring even though a relevant cause is present). Subjects were required to judge whether or not each argument's conclusion could be accepted. Judgements were found to vary systematically with the number of alternative causes and disabling conditions. Conclusions of arguments based on conditionals with few alternative causes or disabling conditions were found to be more acceptable than conclusions based on those with many.
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