An Evaluation of Risk Factors for Intracranial Metastases of Sarcomas: A Systematic Review and Meta-Analysis

INTRODUCTION

Sarcomas, a group of neoplasms comprising both tissue and bone soft tissue tumors, has an increasing prevalence in recent years. Prognosis significantly hinges on early detection and if not detected early may consequently metastasize. This review will be the first systematic review and meta-analysis characterizing the presentation and progression of brain metastases from bone and soft tissue cancers.

METHODS

The PubMed, Scopus, and Web of Science databases were queried to identify studies reporting the incidence of intracranial brain metastases from primary sarcoma to the present. Abstract and full-text screening of 1822 initial articles returned by preliminary search yielded 28 studies for inclusion and data extraction. Qualitative assessment of the studies were conducted in accordance with the Newcastle-Ottawa Scale criteria. Meta-analyses were applied to assess risk factors on outcomes.

RESULTS

The average age within the cohort was 27.9 years with a male and female prevalence of 59.1% and 40.9%, respectively. The odds rato for living status (dead/alive) were calculated for several risk factors - male/female [OR 1.14, 95% CI 0.62, 2.07], single/multiple metastases [OR 0.67, 95% CI 0.35, 1.28], lung metastases/not [OR 1.63, 95% CI 0.85, 3.13], surgery/no surgery [OR 0.49, 95% CI 0.20, 1.21]. The standardized mean differences for duration from diagnoses to metastases were likewise analyzed - male/female [SMD 0.13, 95% CI -0.15, 0.42], single/multiple metastases [SMD 0.11, 95% CI -0.20, 0.42], lung metastases/not [SMD -0.03, 95% CI -0.38, 0.32], surgery/no surgery [SMD 0.45, 95% CI -0.18,1.09]. The standardized mean differences for duration from metastases to death were analyzed - lung metastases/not [SMD 0.43, 95% CI -0.08, 0.95].

CONCLUSION

Our study observed no statistically significant differences in mortality rate among several patient risk factors. Consequentially, there lacks a clear answer as to whether or not an association between mortality rates exists with these patient factors. As such, it is important to continue research in brain-metastasizing sarcomas despite their relative rarity.

Management Considerations for Total Intervertebral Disc Replacement

The burden of disease regarding lumbar and cervical spine pain is a long-standing, pervasive problem within medicine that has yet to be resolved. Specifically, neck and back pain are associated with chronic pain, disability, and exorbitant health care use worldwide, which have only been exacerbated by the increase in overall life years and chronic disease. Traditionally, patients with significant pain and disability secondary to disease of either the cervical or lumbar spine are treated via fusion or discectomy. Although these interventions have proved curative in the short-term, numerous longitudinal studies evaluating the efficacy of traditional management have reported severe impairment of normal spinal range of motion, as well as postoperative complications, including neurologic injury, radiculopathy, osteolysis, subsidence, and infection, paired with less than desirable reoperation rates. Consequently, there is a call for innovation and improvement in the treatment of lumbar and cervical spine pain, which may be answered by a modern technique known as intervertebral disc arthroplasty, or total disc replacement (TDR). Thus, this review aims to describe the management strategy of TDR and to explore updated considerations for its use in practice, both to help guide clinical decision making.

Updates on Neuronavigation: Emerging tools for tumor resection

Multiple studies have been conducted to properly elucidate the various tools available to help enhance the resection of tumor tissue, aneurysms, and arteriovenous malformations (AVM). Diffusion tensor imaging (DTI) tractography is useful in providing a map of the tumor borders, allowing the optimal preservation of function and structure of specific regions of the brain. During neurosurgery, especially craniotomies, the possibility of the brain shifting due to swelling or gravity is high. Thus, tools for intraoperative imaging such as high-frequency linear array ultrasound transducers and doppler ultrasonography are utilized for high resolution images and detecting frequency shifts. 4D-digital subtraction angiography (DSA) is another technique used to create spatial resolutions and 3D maps for aneurysms. These similar techniques can also be utilized to assess the integrity of white matter in AVM. By implementing effective evaluation strategies, healthcare professionals can make informed decisions regarding treatment options, preventive measures, and long-term care plans tailored to individual patients.

Neurologic Injury-Related Predisposing Factors of Post-Traumatic Stress Disorder: A Critical Examination

The present review aimed to identify the means through which neurologic injury can predispose individuals to Post-Traumatic Stress Disorder (PTSD). In recent years, comprehensive studies have helped to clarify which structures in the central nervous system can lead to distinct PTSD symptoms-namely, dissociative reactions or flashbacks-when damaged. Our review narrowed its focus to three common neurologic injuries, traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), and stroke. We found that in each of the three cases, individuals may be at an increased risk of developing PTSD symptoms. Beyond discussing the potential mechanisms by which neurotrauma may lead to PTSD, we summarized our current understanding of the pathophysiology of the disorder and discussed predicted associations between the limbic system and PTSD. In particular, the effect of noradrenergic neuromodulatory signaling on the hypothalamic pituitary adrenal (HPA) axis as it pertains to fear memory recall needs to be further explored to better understand its effects on limbic structures in PTSD patients. At present, altered limbic activity can be found in both neurotrauma and PTSD patients, suggesting a potential causative link. Particularly, changes in the function of the limbic system may be associated with characteristic symptoms of PTSD such as intrusive memories and acute psychological distress. Despite evidence demonstrating the correlation between neurotrauma and PTSD, a lack of PTSD prognosis exists in TBI, SAH, and stroke patients who could benefit from early treatment. It should be noted that PTSD symptoms often compound with pre-existing issues, further deteriorating health outcomes for these patients. It is ultimately our goal to clarify the relationship between neurotrauma and PTSD so that earlier diagnoses and appropriate treatment are observed in clinic.

The protective role of GLP-1 in neuro-ophthalmology

Despite recent advancements in the field of neuro-ophthalmology, the rising rates of neurological and ophthalmological conditions, mismatches between supply and demand of clinicians, and an aging population underscore the urgent need to explore new therapeutic approaches within the field. Glucagon-like peptide 1 receptor agonists (GLP-1RAs), traditionally used in the treatment of type 2 diabetes, are becoming increasingly appreciated for their diverse applications. Recently, GLP-1RAs have been approved for the treatment of obesity and recognized for their cardioprotective effects. Emerging evidence indicates some GLP-1RAs can cross the blood-brain barrier and may have neuroprotective effects. Therefore, this article aims to review the literature on the neurologic and neuro-ophthalmic role of glucagon-like peptide 1 (GLP-1). This article describes GLP-1 peptide characteristics and the mechanisms mediating its known role in increasing insulin, decreasing glucagon, delaying gastric emptying, and promoting satiety. This article identifies the sources and targets of GLP-1 in the brain and review the mechanisms which mediate its neuroprotective effects, as well as implications for Alzheimer's disease (AD) and Parkinson's disease (PD). Furthermore, the preclinical works which unravel the effects of GLP-1 in ocular dynamics and the preclinical literature regarding GLP-1RA use in the management of several neuro-ophthalmic conditions, including diabetic retinopathy (DR), glaucoma, and idiopathic intracranial hypertension (IIH) are discussed.

The Role of Platelet-Rich Plasma Therapy in Joint Arthroplasty A Mini-Review

Orthobiologics are playing an increasingly large role in the clinical setting across multiple fields of surgery. Particularly, in the field of orthopedic surgery, the employment of platelet-rich plasma (PRP) therapy in total joint arthroscopy (TJA) has become popular for its prompted benefits of controlling pain, blood loss, and increased wound healing. PRP was originally used for thrombolytic conditions, however, the aforementioned potential benefits have led to its increased use across various fields of medicine including dermatology, neurosurgery, orthopedics, and sports medicine. Currently, there is a persisting gap in the literature surrounding the mechanism of action of PRP, as well as its true role in increasing positive patient outcomes in the context of TJA. Thus, this review aims to briefly highlight the physiological mechanisms underlining PRP therapy, evaluate recent preclinical and clinical data about its effects on TJA patient outcomes, and to describe its concomitant use in novel orthopedic-applications.

Neurostimulation for Spinal Lesions: Enhancing Recovery and Axonal Regeneration

Spinal neurostimulation is a promising approach for treating spinal lesions and has implications in various neurological disorders. It promotes axonal regeneration and neuronal plasticity to reestablish disrupted signal transduction pathways following spinal injuries or degeneration. This paper reviews the current technology and its differing utilities in various types of neurostimulation, including invasive and noninvasive methods. The paper also explores the efficacy of spinal compression and decompression therapy, with a primary focus on degenerative spinal disorders. Moreover, the potential of spinal neurostimulation in therapies for motor disorders, such as Parkinson's disease and demyelinating disorders, is discussed. Finally, the paper examines the changing guidelines of use for spinal neurostimulation following surgical tumor resection. The review suggests that spinal neurostimulation is a promising therapy for axonal regeneration in spinal lesions. This paper concludes that future research should focus on the long-term effects and safety of these existing technologies, optimizing the use of spinal neurostimulation to enhance recovery and exploring its potential for other neurological disorders.

Vertebral Primary Bone Lesions: Review of Management Options

The assessment and treatment of vertebral primary bone lesions continue to pose a unique yet significant challenge. Indeed, there exists little in the literature in the way of compiling and overviewing the various types of vertebral lesions, which can often have complicated intervention strategies. Given the severe consequences of mismanaged vertebral bone tumors-including the extreme loss of motor function-it is clear that such an overview of spinal lesion care is needed. Thus, in the following paper, we aim to address the assessment of various vertebral primary bone lesions, outlining the relevant nonsurgical and surgical interventional methods. We describe examples of primary benign and malignant tumors, comparing and contrasting their differences. We also highlight emerging treatments and approaches for these tumors, like cryoablation and stereotactic body radiation therapy. Ultimately, we aim to emphasize the need for further guidelines in regard to correlating lesion type with proper therapy, underscoring the innate diversity of vertebral primary bone lesions in the literature.

Diabetes Mellitus Management in the Context of Cranial Tumors

The study of the relationship between cancer and diabetes mellitus (DM) has been under investigation for many decades. Particularly in the field of neurology and neurosurgery, increasing emphasis has been put on the examination of comorbid DM in patients with cranial tumors. Namely, as the most common and invasive type of malignant adult brain tumor, glioblastoma (GBS) has been the focus of said research. Several mechanisms have been described in the attempt to elucidate the underlying association between DM and GBS, with the metabolic phenomenon known as the Warburg effect and its consequential downstream effects serving as the resounding culprits in recent literature. Since the effect seen in cancers like GBS exploits an upregulated form of aerobic glycolysis, the role of a sequela of DM, known as hyperglycemia, will be investigated. In particular, in the treatment of GBS, surgical resection and subsequent chemotherapy and/or radiotherapy are used in conjunction with corticosteroid therapy, the latter of which has been linked to hyperglycemia. Unsurprisingly, comorbid DM patients are significantly susceptible to this disposition. Further, this fact is reflected in recent literature that demonstrates the impact of hyperglycemia on cancer advancement and patient outcomes in several preclinical and clinical studies. Thus, this review will aim to underline the significance of diabetes and glycemic control via standard-of-care treatments such as metformin administration, as well as to describe emerging treatments such as the signaling modulation of insulin-like growth factor and the employment of the ketogenic diet.

Endovascular Chemotherapy: Selective Targeting for Brain Cancer

Establishing an effective and robust management option for brain cancers has proven to bean elusive challenge for the fields of neurosurgery and neuro-oncology. Despite decades of research efforts to improve treatment outcomes and increase patient survivability, brain cancer remains among the most fatal of all cancer classes. A significant barrier to this endeavor is the blood-brain barrier, a major protective border for brain tissue that primarily precludes the optimal delivery of chemotherapeutic drugs to the patient's brain circulation through tight junction formations and selective transporter proteins. This issue is often compounded by tumor location, particularly in inoperable regions near functional brain parenchyma. These obstacles necessitate the development of selectively targeted delivery of chemotherapeutic agents, such as endovascular super-selective intra-arterial injections. Recent experimental studies demonstrate the effectiveness of focused ultrasound to unseal the blood-brain barrier selectively and reversibly. Together, these new technologies can be leveraged to circumvent the limited permeability of the blood-brain barrier, thus improving drug delivery to tumoral locations and potentially enabling a more effective treatment alternative to surgical resection. This review attempts to place into context the necessity of these newer selective chemotherapeutic modalities by briefly highlighting commonly encountered brain cancers and explaining the prominent challenges that face chemotherapy delivery, as well as describing the current preclinical and clinical progress in the development of facilitatory focused ultrasound with selective endovascular chemotherapy.

Hepatitis B-related polyarteritis nodosa complicated by pulmonary hemorrhage

A 34-year-old man presented with fever, weight loss, paresthesia, abdominal pain, and hypertension. He had hepatitis B antigenemia, with negative antineutrophil cytoplasmic antibody, antinuclear antibody, and antiglomerular basement membrane serology results. Renal arteriography showed multiple intrarenal microaneurysms. In spite of therapy with antiviral agents (lamivudine, famciclovir), prednisone, cyclophosphamide, and plasmapheresis, renal function deteriorated. He later developed rapidly progressive dyspnea and hemoptysis. Diffuse alveolar hemorrhage was confirmed by bronchoscopy. He died of respiratory failure. The cause of pulmonary hemorrhage in this case of polyarteritis nodosa is unclear, but may include underlying capillaritis, cocaine-induced pulmonary hemorrhage, or recurrent attacks of malignant hypertension.

Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals

OBJECTIVE

The purpose of this study was to describe the recognition and management of delirium in hospitalized patients with and without dementia.

DESIGN

A descriptive, exploratory design was used with a convenience sample of 20 hospitalized older patients who were observed indepth using qualitative interviews and observations of 13 family members and 11 staff members.

SETTING

This research was conducted on the medical-surgical units of a 550-bed, nonprofit, state-supported teaching hospital in the southeastern United States. The facility provides primary and tertiary care with five intensive care units and eight medical-surgical units.

PARTICIPANTS

This study did not exclude individuals with dementia or pre-existing delirium. Subjects were not excluded on the basis of race or gender. Twenty patients in the sample underwent observation and mental and functional status testing. Thirteen family members and 11 staff members were interviewed and observed.

MEASUREMENTS

In Phase 1 of the study, patients had daily mental status testing performed by the investigator. In Phase 2, family members and staff members were interviewed about the confusion event. For each patient, demographics and information regarding their health status and current diagnosis and treatment were obtained. The Mini-Mental State Examination (MMSE) and the Confusion Assessment Method were completed on each subject within 36 hours of being admitted to the hospital. The Cornell Depression Scale and Katz Activities of Daily Living scale were completed within 48 hours of admission.

RESULTS

The prevalence of delirium in this study was 60%. The incidence, or new onset of delirium, was 30%. The presence of delirium was associated with new onset incontinence, lower baseline MMSE scores, depression, weight loss, and comorbidity. Of the eight individuals with delirium superimposed on dementia, 63% (n = 5) were re-admitted to the hospital within 30 days, compared to none of the individuals with delirium in the absence of dementia. Delirium superimposed on dementia also was less likely to be recognized by nurses and physicians.

CONCLUSIONS

Delirium in individuals with dementia should be assessed and treated routinely because the failure to recognize delirium superimposed on dementia promptly has significant negative personal, social and financial consequences.

Induction of alpha1-tubulin gene expression during development and regeneration of the fish central nervous system

The alpha1- and alpha2-tubulin encoding genes were cloned from a goldfish genomic DNA library. alpha1- and alpha2-tubulin RNA expression was examined in developing and adult retinas. These studies demonstrated increased alpha1-tubulin RNA in presumptive ganglion cells that grow axons early in retinal development and in adult retinal ganglion cells whose optic axons had been damaged. The alpha2-tubulin RNA was undetectable in developing retina and constitutively expressed in adult retinal ganglion cells regardless of optic nerve crush. To determine if these changes in alpha1-tubulin RNA reflected changes in alpha1-tubulin promoter activity, we introduced into zebrafish embryos and adult goldfish retinal explants expression vectors harboring the alpha1-tubulin gene's promoter. These studies showed that the alpha1-tubulin promoter confers a developmentally regulated, neuron-restricted pattern of reporter gene expression in vivo and its activity is increased in adult retinal neurons induced to regenerate their axons. Promoter deletions defined regions of alpha1-tubulin DNA necessary for this pattern of expression. These results suggest that DNA sequences necessary for alpha1-tubulin gene induction during central nervous system development and regeneration are contained within the alpha1-tubulin gene's 5'-flanking DNA and that this promoter will be useful for identifying these elements and their DNA binding proteins.

Extracorporeal whole body hyperthermia treatment of HIV patients, a feasibility study

The literature supports that the retrovirus, Human Immunodeficiency Virus (HIV), which is thought to cause Acquired Immunodeficiency Syndrome (AIDS), is heat sensitive at temperatures which can be achieved in man. Invasive or non-invasive induction of whole body hyperthermia (WBH) has been used to treat an array of illnesses, primarily in the field of oncology, until recently. Non-invasive methods have proven to be less toxic than invasive means. However, new technology and refined patient management have shown a dramatic decrease in the side effects with extracorporeal whole body hyperthermia (EWBH). The Food and Drug Administration granted a prospective trial for six HIV positive/AIDS patients to undergo a single treatment of EWBH, with patients randomized to a core temperature of either 41 or 42 degrees C. All patients had failed antiretrovirals and experienced at least one episode of an opportunistic infection. Organetics, Ltd., PS-1 extracorporeal, centrifugal pump device was used to induce EWBH. Results of this feasibility study demonstrated the ability of this equipment and technique to induce EWBH with acceptable toxicity. It was not possible to assess efficacy in this small study.

Are men taking over the nursing profession?

Although men are a minority in the nursing profession, many men obtain senior positions and hence their motivation for becoming registered nurses is often questioned. International nursing literature is used to clarify why men may want to become nurses and to suggest possible reasons for the gender inequities in senior nursing appointments.

Satisfaction of nurse managers in long-term care

Nurse managers control quality and cost of the principal service provided by long-term care agencies. Job satisfaction was higher for long-term care nurse managers in metropolitan than in rural or suburban agencies. Findings suggest that continuing education may increase task satisfaction, as well as job knowledge of diploma-prepared nurse managers.

Detecting delirium among hospitalized older patients

BACKGROUND

Delirium occurs commonly among older hospitalized patients and is frequently not recognized. In an effort to identify tools useful to clinicians in the diagnosis of delirium, test characteristics of four screening instruments were compared.

METHODS

Patients 65 years of age or older who were admitted to one of four medical and surgical wards of a university teaching hospital were followed up prospectively. Potential subjects were excluded if unavailable for interviews or discharged within 48 hours of admission, or if judged too impaired to participate in the daily interviews. Research assistants administered four instruments used to detect delirium: Digit Span Test, Vigilance 'A' Test, Clinical Assessment of Confusion, and Confusion Assessment Method. Abnormal scores on these tests or suspicion of acute confusion prompted a referral to the clinician-investigators who then assessed the patient daily for delirium based on the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria.

RESULTS

Delirium occurred in 64 (14.8%) of 432 subjects. The positive likelihood ratios for all of the instruments were significantly more than 1. The instruments remained useful when applied to selected subgroups: subjects in whom acute mental status changes were documented, subjects on surgical services, and subjects with impaired cognitive status on admission. Combinations of any two instruments did not perform substantially better than the instrument with the best test characteristics: the Clinical Assessment of Confusion. All instruments were more useful at confirming delirium than in excluding it.

CONCLUSION

The four instruments studied, which are suitable for use at the bedside, can aid the clinician in identifying patients likely to be suffering from delirium.

Delirium in hospitalized older persons: outcomes and predictors

OBJECTIVE

The purpose of this study was fourfold; to determine the rate of delirium among hospitalized older persons, to contrast the clinical outcomes of patients with and without delirium, to identify clinical predictors of delirium, and to validate the predictive model in an independent sample of patients.

DESIGN

Two prospective cohort studies

SETTING

Medical and surgical wards of 2 university teaching hospitals.

PATIENTS

In the derivation cohort, 432 patients were enrolled from the University of Chicago Hospitals. Patients 65 years of age or older admitted to 1 of 4 wards were eligible. Subjects were excluded if they were discharged within 48 hours of admission, unavailable to the research assistants during the first 2 days of hospitalization, or judged too impaired to participate in the daily interviews. In the test cohort, 323 patients 70 years of age or older admitted to Yale-New Haven Hospital were studied.

MEASUREMENTS

Subjects were screened for delirium daily and referred to experienced clinician investigators if acute mental status changes were observed. The clinician investigators assessed the patient for delirium based on DSM-III-R criteria. Duration of hospitalization was adjusted for diagnosis-related groups (DRG) and mortality rates were determined at discharge and 90 days after discharge. Sociodemographic characteristics, cognitive and functional status, comorbidity, depression, and alcoholism were examined as predictors of delirium.

MAIN RESULTS

The rate of delirium in the derivation cohort was 15%; subjects with delirium had longer hospital stays and an increased risk of in-hospital death. Cognitive impairment, burden of comorbidity, depression, and alcoholism were found to be independent predictors of delirium. The ability of the model to stratify patients as low, moderate, or high risk for developing delirium was validated in the test cohort in which the rate of delirium was 26%.

CONCLUSIONS

This study confirms the high rate of delirium among hospitalized older persons and the associated adverse outcomes of prolonged hospital stays and increased risk of death. Patients can be stratified according to their risk for developing delirium using relatively few clinical characteristics which should be assessed, on all hospitalized older persons.

Intermittent back pain after central venous catheter placement

We report a case of inadvertent azygos placement of a central venous catheter. The patient experienced ill-defined back pain associated with total parenteral nutrition infusion. The catheter malposition remained unrecognized and resulted in extensive diagnostic work-up. Symptoms resolved after the catheter was withdrawn.

Banach-Tarski paradox using pieces with the property of Baire

In 1924 Banach and Tarski, using ideas of Hausdorff, proved that there is a partition of the unit sphere S2 into sets A1,...,Ak,B1,..., Bl and a collection of isometries [sigma1,..., sigmak, rho1,..., rhol] so that [sigma1A1,..., sigmakAk] and [rho1B1,..., rholBl] both are partitions of S2. The sets in these partitions are constructed by using the axiom of choice and cannot all be Lebesgue measurable. In this note we solve a problem of Marczewski from 1930 by showing that there is a partition of S2 into sets A1,..., Ak, B1,..., Bl with a different strong regularity property, the Property of Baire. We also prove a version of the Banach-Tarski paradox that involves only open sets and does not use the axiom of choice.

Strategy for detection and differentiation of Coxiella burnetii strains using the polymerase chain reaction

A method for the rapid detection of Coxiella burnetii and differentiation between strains that cause endocarditis and those that cause acute Q fever is based on the observation that the different strains contain unique plasmid sequences. This method employs the polymerase chain reaction (PCR) and requires knowledge of specific DNA sequences in the region (target) of DNA to be amplified. To detect and differentiate between C. burnetii isolates, two sets of primers are required. The first set was derived from a fragment of plasmid QpH1 which has been detected in all C. burnetii isolates. A second PCR reaction was conducted using primers specific for DNA sequences that are shared only by QpRS plasmid-containing strains of C. burnetii. The first reaction detects the presence of C. burnetii. The second PCR is necessary to determine whether the isolate contains DNA sequences associated with strains causing chronic disease. These procedures detect as few as one to ten organisms.

Sonographic characterization of carotid plaque: detection of hemorrhage

By careful evaluation of the sonographic characteristics of carotid plaques, two patterns can be identified: a homogeneous pattern containing uniform echoes corresponding to dense fibrous tissue and a heterogeneous pattern containing mixed echoes and anechoic areas that represent intraplaque hemorrhage pathologically. A prospective study was conducted of 50 patients to determine the accuracy of identifying these different forms of plaque. The patients' carotid arteries were examined by a high-resolution duplex scanner before carotid endarterectomy. The plaques were evaluated carefully by vascular surgeons and pathologists for the presence of intraplaque hemorrhage. In this study, the accuracy of identifying the presence or absence of intraplaque hemorrhage with sonography was 90% (48 of 54); sensitivity, 94% (17 of 18); and specificity, 88% (27 of 31). High-resolution sonography appears to be an accurate means of identifying intraplaque hemorrhage and may ultimately be useful in identifying patients at risk for embolic disease.