Publications by authors named "Ronald Sahyouni"

73 Publications

Selective Facial Muscle Activation with Acute and Chronic Multichannel Cuff Electrode Implantation in a Feline Model.

Ann Otol Rhinol Laryngol 2021 Jun 6:34894211023218. Epub 2021 Jun 6.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA, USA.

Objectives: Facial paralysis is a debilitating condition with substantial functional and psychological consequences. This feline-model study evaluates whether facial muscles can be selectively activated in acute and chronic implantation of 16-channel multichannel cuff electrodes (MCE).

Methods: Two cats underwent acute terminal MCE implantation experiments, 2 underwent chronic MCE implantation in uninjured facial nerves (FN) and tested for 6 months, and 2 underwent chronic MCE implantation experiments after FN transection injury and tested for 3 months. The MCE were wrapped around the main trunk of the skeletonized FN, and data collection consisted of EMG thresholds, amplitudes, and selectivity of muscle activation.

Results: In acute experimentation, activation of specific channels (ie, channels 1-3 and 6-8) resulted in selective activation of , whereas activation of other channels (ie, channels 4, 5, or 8) led to selective activation of with higher EMG amplitudes. MCE implantation yielded stable and selective facial muscle activation EMG thresholds and amplitudes up to a 5-month period. Modest selective muscle activation was furthermore obtained after a complete transection-reapproximating nerve injury after a 3-month recovery period and implantation reoperation. Chronic implantation of MCE did not lead to fibrosis on histology. Field steering was achieved to activate distinct facial muscles by sending simultaneous subthreshold currents to multiple channels, thus theoretically protecting against nerve damage from chronic electrical stimulation.

Conclusion: Our proof-of-concept results show the ability of an MCE, supplemented with field steering, to provide a degree of selective facial muscle stimulation in a feline model, even following nerve regeneration after FN injury.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1177/00034894211023218DOI Listing
June 2021

Determinants of Survival in Skull Base Osteosarcoma: A National Cancer Database Study.

World Neurosurg 2021 May 8. Epub 2021 May 8.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, USA; Department of Neurological Surgery, University of California, Irvine, Irvine, California, USA. Electronic address:

Objective: Skull base osteosarcoma is a rare and aggressive tumor that is most commonly treated with primary surgical resection and adjuvant chemoradiation. Using the National Cancer Database, we analyzed demographic and clinical prognosticators for overall survival (OS).

Methods: The National Cancer Database was queried for cases of histologically confirmed skull base osteosarcoma treated between 2004 and 2015, excluding patients receiving palliation or having <1 month of follow-up. A total of 314 patients treated with surgery alone (n = 82), surgery with adjuvant radiotherapy (n = 35), surgery with chemotherapy (n = 114), or trimodality therapy (n = 56) were identified. The χ test for categorical variables, Cox proportional hazards models, and Kaplan-Meier log-rank analysis were used to test associations with treatment, OS, and survival time.

Results: None of the studied demographic characteristics (age, sex, race, overall health) and socioeconomic factors (income and average regional education) were associated with OS (none P < 0.05). Treatment modalities also did not show a significant association with OS (none P < 0.05). Certain tumor characteristics showed an association with OS, with fibroblastic and Paget histologic subtypes (each P = 0.003), poorly differentiated tumor grade (P = 0.03), and tumor size >5 cm (P = 0.045) associated with poorer OS.

Conclusions: Tumor histologic subtype, advanced tumor grade, and greater tumor size are predictors of worse OS in skull base osteosarcoma. No significant differences in OS were identified based on treatment modality, which warrants further investigation.
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http://dx.doi.org/10.1016/j.wneu.2021.04.135DOI Listing
May 2021

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

Patient Saf Surg 2021 Apr 29;15(1):19. Epub 2021 Apr 29.

University of California, Los Angeles, CA, USA.

At the time of writing of this article, there have been over 110 million cases and 2.4 million deaths worldwide since the start of the Coronavirus Disease 2019 (COVID-19) pandemic, postponing millions of non-urgent surgeries. Existing literature explores the complexities of rationing medical care. However, implications of non-urgent surgery postponement during the COVID-19 pandemic have not yet been analyzed within the context of the four pillars of medical ethics. The objective of this review is to discuss the ethics of elective surgery cancellation during the COVID-19 pandemic in relation to beneficence, non-maleficence, justice, and autonomy. This review hypothesizes that a more equitable decision-making algorithm can be formulated by analyzing the ethical dilemmas of elective surgical care during the pandemic through the lens of these four pillars. This paper's analysis shows that non-urgent surgeries treat conditions that can become urgent if left untreated. Postponement of these surgeries can cause cumulative harm downstream. An improved algorithm can address these issues of beneficence by weighing local pandemic stressors within predictive algorithms to appropriately increase surgeries. Additionally, the potential harms of performing non-urgent surgeries extend beyond the patient. Non-maleficence is maintained through using enhanced screening protocols and modifying surgical techniques to reduce risks to patients and clinicians. This model proposes a system to transfer patients from areas of high to low burden, addressing the challenge of justice by considering facility burden rather than value judgments concerning the nature of a particular surgery, such as cosmetic surgeries. Autonomy can be respected by giving patients the option to cancel or postpone non-urgent surgeries. However, in the context of limited resources in a global pandemic, autonomy is not absolute. Non-urgent surgeries can ethically be postponed in opposition to the patient's preference. The proposed algorithm attempts to uphold the four principles of medical ethics in rationing non-urgent surgical care by building upon existing decision models, using additional measures of resource burden and surgical safety to increase health care access and decrease long-term harm as much as possible. The next global health crisis will undoubtedly present its own unique challenges. This model may serve as a comprehensive starting point in determining future guidelines for non-urgent surgical care.
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http://dx.doi.org/10.1186/s13037-021-00293-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082741PMC
April 2021

Surgical management of a rare myxopapillary ependymoma of the gluteal region: A case report.

Surg Neurol Int 2021 30;12:130. Epub 2021 Mar 30.

Department of Neurological Surgery, University of California, UCI Medical Center, Orange, United States.

Background: Ependymomas are rare tumors originating from neuroepithelial cells lining the wall of the ventricles or central canal of the spinal cord. While these tumors mainly occur within the central nervous system (CNS), there are occasional reports in children and young adult patients with a primary tumor occurrence outside of the CNS. Ependymomas of the sacrococcygeal region have been infrequently described in the literature with no standard of care established. We present a case report and review of the literature regarding this rare entity.

Case Description: A 24-year-old woman presented with right gluteal pain worsened by sitting and a palpable soft tissue mass of the sacrococcygeal region. Magnetic resonance imaging revealed a 3.7 cm cystic mass centered in the right gluteal region. She underwent a biopsy at an outside institution, with histology revealing myxopapillary ependymoma. The patient was referred to our hospital and underwent an interdisciplinary neurosurgical and orthopedic oncology en bloc resection of the ependymoma, which intraoperatively appeared to originate from the coccygeal nerve.

Conclusion: In the present report, the authors demonstrate that a myxopapillary ependymoma may present as an isolated gluteal mass attached to the coccygeal nerve, without frank CNS involvement. Furthermore, an interdisciplinary approach to surgical resection of this lesion appears to represent an effective treatment modality.
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http://dx.doi.org/10.25259/SNI_768_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053468PMC
March 2021

Getting Down to the Bare Bones: Does laminoplasty or laminectomy With Fusion Provide Better Outcomes for Patients With Multilevel Cervical Spondylotic Myelopathy?

Neurospine 2021 Mar 31;18(1):45-54. Epub 2021 Mar 31.

Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA.

Objective: Cervical spondylotic myelopathy (CSM) is a degenerative disorder leading to progressive decline in spinal cord function. Cervical laminoplasty (CLP) and cervical laminectomy with fusion (CLF) are standard treatments for multilevel CSM. However, it is still unclear whether one procedure over the other provides better outcomes. Here, we performed a comprehensive review of published articles that compare the clinical outcomes and costs between CLP and CLF for CSM.

Methods: A literature search was performed using PubMed, Web of Science, and Cochrane databases. Strict exclusion criteria were applied, and included articles were then assessed for publication year, study design, and significant differences in outcome variables.

Results: From 519 studies identified with search terms, 38 studies were included for the qualitative analysis. Statistically significant differences in the clinical outcomes and costs were found in 18 studies. Eleven studies were prospective or retrospective, and 8 studies were meta-analyses. For the outcome variables of interest, results were reported by classifying into prospective studies, retrospective studies, and meta-analyses.

Conclusion: CLP and CLF are 2 of the most commonly performed surgical procedures for the treatment of CSM. Although CLP and CLF each provide satisfactory clinical outcomes for patients with CMS, CLP may result in better cervical range of motion and less cost, length of stay, operation time, blood loss, paraspinal muscular atrophy, and rate of nerve palsies as compared to CLF. The major limitation of CLP versus CLF comparison studies includes the heterogeneity in techniques and preoperative criteria. Thus, further validation and investigations in larger cohorts will be required.
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http://dx.doi.org/10.14245/ns.2040520.260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021836PMC
March 2021

Effectiveness of Repair Techniques for Spinal Dural Tears: A Systematic Review.

World Neurosurg 2021 May 25;149:140-147. Epub 2021 Feb 25.

Department of Neurological Surgery, University of California, Irvine, California, USA. Electronic address:

Background: Incidental or intentional durotomy in spine surgery is associated with a risk of cerebrospinal fluid (CSF) leakage and reoperation. Several strategies have been introduced, but the incomplete closure is still relatively frequent and troublesome. In this study, we review current evidence on spinal dural repair strategies and evaluate their efficacy.

Methods: PubMed, Web of Science, and Scopus were used to search primary studies about the repair of the spinal dura with different techniques. Of 265 articles found, 11 studies, which specified repair techniques and postoperative outcomes, were included for qualitative and quantitative analysis. The primary outcomes were CSF leakage and postoperative infection.

Results: The outcomes of different dural repair techniques were available in 776 cases. Pooled analysis of 11 studies demonstrated that the most commonly used technique was a combination of primary closure, patch or graft, and sealant (22.7%, 176/776). A combination of primary closure and patch or graft resulted in the lowest rate of CSF leakage (5.5%, 7/128). In this study, sealants as an adjunct to primary closure (13.7%, 18/131) did not significantly reduce the rate of CSF leakage compared with primary closure alone (17.6%, 18/102). The rates of infection and postoperative neurologic deficit were similar regardless of the repair techniques.

Conclusions: Although the use of sealants has become prevalent, available sealants as an adjunct to primary closure did not reduce the rate of CSF leakage compared with primary closure. The combination of primary closure and patches or grafts could be effective in decreasing postoperative CSF leakage.
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http://dx.doi.org/10.1016/j.wneu.2021.02.079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102333PMC
May 2021

Cervical Arthroplasty in the Treatment of Cervical Angina: Case Report and Review of the Literature.

Neurospine 2020 Dec 31;17(4):929-938. Epub 2020 Dec 31.

Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, CA, USA.

Cervical angina is an often-overlooked etiology of noncardiac chest pain that may mimic true angina pectoris but is due to cervical spine disease. Diagnosis can be difficult, and treatment ranges from conservative therapy to surgical management. However, of patient's refractory to conservative therapy, approximately ninety percent experience postoperative relief of angina symptoms. Here, we present a case report on cervical angina and performed a systematic review of the literature. A 34-year-old male with prior surgery for thoracic outlet syndrome presented with persistent anterior neck and chest pain as well as posterior left scapular and upper lateral arm pain. The pain was refractory to 12 months of conservative therapy. Cardiac workup was negative and cervical spine imaging revealed a C6-7 herniation with neuroforaminal stenosis. A systematic literature search was conducted in PubMed, Web of Science, and Cochrane databases from database inception to April 2020. Studies reporting cervical level, average symptom duration, location of pain, and postoperative pain improvement were included. The patient's atypical symptoms were completely resolved after C6-7 anterior cervical discectomy and arthroplasty. To our knowledge, this is the first study which reports on the use of arthroplasty in the treatment of cervical angina. The systematic review included 11 articles from 1989-2020 consisting of 1,186 total patients and 109 patients (age range, 36-84 years; 60.7% male) meeting inclusion criteria. Symptom duration range was 2 days to 90 months, with the most common location of pain being localized to the anterior chest wall (66.7% of patients). All patients (100%) had postoperative resolution of their pain symptoms. The most common herniation level was C6-7 (87.3% of patients). We conclude that a broad and multidisciplinary approach is necessary for the diagnosis and management of noncardiac chest pain. When cervical disease is identified as the underlying cause for the angina-like pain, conservative therapy should be sought. Refractory cases should be treated surgically depending on the cervical pathology.
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http://dx.doi.org/10.14245/ns.2040074.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788421PMC
December 2020

Spinal pathologies and management strategies associated with cervical angina (pseudoangina): a systematic review.

J Neurosurg Spine 2020 Dec 4:1-8. Epub 2020 Dec 4.

1School of Medicine, University of California, Irvine, California.

Objective: Cervical angina, or pseudoangina pectoris, is a noncardiac syndrome of chest pain that often mimics angina pectoris but is a disease of the spine. Diagnosis of cervical angina can be difficult and is often overlooked, although once identified, it can be successfully managed through conservative therapies and/or a variety of surgical interventions. Ultimately, cervical angina is an important component of the list of differential diagnoses in noncardiac chest pain. In the present study, the authors report the first comprehensive systematic review of the range of cervical and thoracic pathologies associated with cervical angina, as well as the different treatment methods used to manage this condition.

Methods: A systematic review was performed according to PRISMA guidelines and using PubMed, Web of Science, and Cochrane databases from database inception to April 29, 2020, to identify studies describing spinal pathologies related to cervical angina. The following Boolean search was performed: ("cervical" OR "thoracic") AND ("angina" OR "chest pain") AND ("herniation" OR "OPLL"). Variables extracted included patient demographics, cervical angina pain location, pathology and duration of symptoms, treatment and/or management method, and posttreatment pain relief.

Results: Upon careful screening, 22 articles published between 1976 and 2020 met the study's inclusion/exclusion criteria, including 5 case series, 12 case reports, and 5 retrospective cohort studies. These studies featured a total of 1100 patients, of which 95 met inclusion criteria (mean patient age 51.7 years, age range 24-86 years; 53.6% male). Collectively, symptom durations ranged from 1.5 days to 90 months. Cervical herniation (72.6%) accounted for the majority of cervical angina cases, and surgical interventions (84.4%) predominated over physical therapy (13.0%) and medical management strategies (9.1%). Every patient assessed at follow-up reported relief from symptoms related to cervical angina.

Conclusions: Cervical angina is a noncardiac syndrome of chest pain associated with a broad range of cervical and thoracic spinal pathologies, the most common of which is cervical disc herniation. Although difficult to diagnose, it can be successfully treated when identified through first-line conservative management or surgical interventions in refractory cases.
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http://dx.doi.org/10.3171/2020.7.SPINE20866DOI Listing
December 2020

Predictors of Patient Satisfaction in Spine Surgery: A Systematic Review.

World Neurosurg 2021 Feb 28;146:e1160-e1170. Epub 2020 Nov 28.

Department of Neurosurgery, University of California, Irvine, Irvine, California, USA.

Background: Recently, there has been increased interest in patient satisfaction measures such as Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. In this systematic review, the spine surgery literature is analyzed to evaluate factors predictive of patient satisfaction as measured by these surveys.

Methods: A thorough literature search was performed in PubMed/MEDLINE, Google Scholar, and Cochrane databases. All English-language articles from database inception to July 2020 were screened for study inclusion according to PRISMA guidelines.

Results: Twenty-four of the 1899 published studies were included for qualitative analysis. There has been a statistically significant increase in the number of publications across years (P = 0.04). Overall, the studies evaluated the relationship between patient satisfaction and patient demographics (71%), preoperative and intraoperative clinical factors (21%), and postoperative factors (33%). Top positive predictors of patient satisfaction were patient and nursing/medical staff relationship (n = 4; 17%), physician-patient relationship (n = 4; 17%), managerial oversight of received care (n = 3; 13%), same sex/ethnicity between patient and physician (n = 2; 8%), and older age (n = 2; 8%). Top negative predictors of patient satisfaction were high Charlson Comorbidity Index/high disability/worse overall health functioning (n = 7; 29%), increased length of hospital stay (n = 4; 17%), high rating for pain/complications/readmissions (n = 4; 17%), and psychosocial factors (n = 3; 13%).

Conclusions: There is heterogeneity in terms of different factors, both clinical and nonclinically related, that affect patient satisfaction ratings. More research is warranted to investigate the role of hospital consumer surveys in the spine surgical patient population.
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http://dx.doi.org/10.1016/j.wneu.2020.11.125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897306PMC
February 2021

Indication-based analysis of patient outcomes following deep brain stimulation surgery.

Clin Neurol Neurosurg 2021 01 16;200:106372. Epub 2020 Nov 16.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Background: While considered a safe operation, deep brain stimulation (DBS) has been associated with various morbidities. We assessed differences in postsurgical complication rates in patients undergoing the most common types of neurostimulation surgery.

Methods: The National Readmission Database (NRD) was queried to identify patients undergoing neurostimulation placement with the diagnosis of Parkinson disease (PD), epilepsy, dystonia, or essential tremor (ET). Demographics and complications, including infection, pneumonia, and neurostimulator revision, were queried for each cohort and compiled. Readmissions were assessed in 30-, 90-, and 180-day intervals. We implemented nearest-neighbor propensity score matching to control for demographic and sample size differences between groups.

Results: We identified 3230 patients with Parkinson disease, 1289 with essential tremor, 965 with epilepsy, and 221 with dystonia. Following propensity score matching, 221 patients remained in each cohort. Readmission rates 30-days after hospital discharge for PD patients (15.5 %) were significantly greater than those for ET (7.8 %) and seizure patients (4.4 %). Pneumonia was reported for PD (1.6 %), seizure (3.3 %) and dystonia (1.7 %) patients but not individuals ET. No PD patients were readmitted at 30-days due to dysphagia while individuals treated for ET (6.5 %), seizure (1.6 %) and dystonia (5.2 %) were. DBS-revision surgery was performed for 11.48 % of PD, 6.52 % of ET, 1.64 % of seizure and 6.90 % of dystonia patients within 30-days of hospital discharge.

Conclusion: 30-day readmission rates vary significantly between indications, with patients receiving DBS for PD having the highest rates. Further longitudinal studies are required to describe drivers of variation in postoperative outcomes following DBS surgery for different indications.
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http://dx.doi.org/10.1016/j.clineuro.2020.106372DOI Listing
January 2021

The 100 Most Influential Publications on Medulloblastoma: Areas of Past, Current, and Future Focus.

World Neurosurg 2021 02 16;146:119-139. Epub 2020 Nov 16.

Department of Neurological Surgery, University of California, Los Angeles, California, USA.

Background: This article is the first to identify the most influential articles on medulloblastoma using the citation analysis methodology.

Objective: To perform a bibliometric analysis of the 100 most-cited articles on medulloblastoma.

Methods: Using the Web of Science database, search criteria included the title-specific keyword "medulloblastoma" OR "cerebellar primitive neuroectodermal tumor (PNET)" OR "cerebellar PNET." Publications from 1900 to 2020 labeled "article," "review," "data set," or "clinical trial" were chosen and ranked based on total number of citations in descending order. Each article was evaluated based on the following variables: total citations, average citations per year, first author, institution of first author, title, publication year, country of origin, SCImago Journal Rank, and Scopus SNIP (Source Normalized Impact per Paper).

Results: Our search yielded 4928 articles on medulloblastoma. The 100 most-cited articles ranged from 192 to 2017 across 42 unique journals; Journal of Clinical Oncology accounted for the most publications (16%). Paul A. Northcott was first author of the most articles on the list (n = 7.7%), and the most widely cited article was "Altered neural cell fates and medulloblastoma in mouse patched mutants" by Goodrich et al., published in Science (1997).

Conclusions: Because medulloblastoma represents the most common form of pediatric cancerous brain tumor, it is important to identify works that have significantly contributed to the body of knowledge regarding this disease. The 100 most-cited medulloblastoma articles comprise a significant collection of data regarding the histopathologic and molecular classification of medulloblastoma as well as clinical outcomes of therapeutics used to treat this disease.
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http://dx.doi.org/10.1016/j.wneu.2020.11.038DOI Listing
February 2021

The market landscape of online second opinion services for spine surgery.

Surg Neurol Int 2020 29;11:365. Epub 2020 Oct 29.

Department of Neurological Surgery, Irvine Medical Center, San Diego, La Jolla, CA, United States.

Background: The aim of this study was to identify patient interest in second opinion services online and identify the options patients have in obtaining second opinions from spine surgeons in the United States.

Methods: We utilized Google Trends (i.e., search data since 2010) to ascertain the level of interest in receiving second opinions for spinal surgery. In addition, we contacted the top 30 hospitals for neurology and neurosurgery in the U.S. News rankings by phone to obtain information regarding when/how and at what cost they provide second opinions for spine surgery.

Results: The cost of the second surgical opinions averaged $493 (±$343) USD (range $90-$1,300); the time to receive a second opinion averaged 20 (±19) days (range 1 day-5 months). Remote or "online second opinion" programs charged an average of $643 (±$259) USD (range $100-$850), and the time to receive an "online second opinion" averaged 14 (±7) days (range 1-4 weeks).

Conclusion: Although second opinions have been shown to be beneficial to patients, ambiguous or high costs and long wait times may serve as barriers for certain groups (i.e., uninsured or underinsured) and potentially diminish the quality of care.
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http://dx.doi.org/10.25259/SNI_577_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656044PMC
October 2020

Spontaneous Involution of Juvenile Nasopharyngeal Angiofibromas: Report of a Case.

Laryngoscope 2021 07 11;131(7):1455-1457. Epub 2020 Nov 11.

Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, California, U.S.A.

Juvenile nasopharyngeal angiofibroma (JNA) is a locally aggressive tumor that predominantly affects adolescent males. Surgical resection is generally considered the standard treatment for both primary and recurrent tumors, regardless of staging. The natural history of these tumors, particularly when untreated or in the setting of residual tumor, is not well characterized. In this article, we report a case of true spontaneous JNA involution. Although the involution of residual tumor after surgical resection has previously been reported, to our knowledge, this is the first documented case of spontaneous JNA involution following a period of tumor growth post-treatment. Laryngoscope, 131:1455-1457, 2021.
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http://dx.doi.org/10.1002/lary.29246DOI Listing
July 2021

Translational Approaches to Electrical Stimulation for Peripheral Nerve Regeneration.

Neurorehabil Neural Repair 2020 11 10;34(11):979-985. Epub 2020 Oct 10.

University of California, San Diego, La Jolla, CA, USA.

Background: Achieving functional repair after peripheral nerve injury (PNI) remains problematic despite considerable advances in surgical technique. Therein, questions lie regarding the variable capacity of peripheral nerves to regenerate based on environmental influence. In-depth analyses of multiple therapeutic strategies have ensued to overcome these natural obstacles. Of these candidate therapies, electrical stimulation has emerged a frontrunner. Extensive animal studies have reported the ability of brief intraoperative electrical stimulation (BES) to enhance functional regeneration after PNI. Despite these reports, the exact mechanisms by which BES enhances regeneration and its effects on long nerve lesions are largely unknown. Indeed, clinical translation of this seemingly simple therapeutic has not been so simple, but a few studies performed in humans have yielded highly encouraging results.

Objective: We aimed to help bridge this translational gap by presenting the latest clinical trials on electrical stimulation for PNIs in combination with relevant etiologies, treatments and nonclinical findings.

Methods: To do so, a systematic search was performed on PubMed, IEEE, and Web of Science databases up to February 2020 using keywords significant to our study. References of each manuscript were screened for additional manuscripts of relevance to our study.

Results: We found multiple BES clinical studies reporting enhanced functional recovery or increased nerve regeneration. Although improved outcomes were reported, high variability after BES is seen between and within species likely due to injury severity, location and timeline along with other factors.

Conclusion: Further clinical studies and introduction of novel delivery platforms are vital to uncover the true regenerative potential of electrical stimulationtherapy.
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http://dx.doi.org/10.1177/1545968320962508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655605PMC
November 2020

Metastatic epidural spinal column compression due to pancreatic ductal adenocarcinoma causing subacute Cauda equina syndrome: A case report.

Surg Neurol Int 2020 5;11:279. Epub 2020 Sep 5.

Department of Neurological Surgery, University of California, San Diego, La Jolla.

Background: Pancreatic ductal adenocarcinoma (PDAC) is the most common pancreatic malignancy, which rarely metastasizes to the spine.

Case Description: Here, we present a lytic lumbar metastatic PDAC resulting in severe epidural spinal cord compression (ESCC) with instability. The lesion required preoperative particle embolization, surgical decompression, and fusion.

Conclusion: This case report shows that PDAC may metastasize to the lumbar spine requiring routine decompression with fusion.
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http://dx.doi.org/10.25259/SNI_514_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538966PMC
September 2020

The role of frailty in geriatric cranial neurosurgery for primary central nervous system neoplasms.

Neurosurg Focus 2020 10;49(4):E15

8Department of Neurological Surgery, University of California, San Diego, La Jolla, California.

Objective: Frailty is a clinical state of increased vulnerability due to age-associated decline and has been well established as a perioperative risk factor. Geriatric patients have a higher risk of frailty, higher incidence of brain cancer, and increased postoperative complication rates compared to nongeriatric patients. Yet, literature describing the effects of frailty on short- and long-term complications in geriatric patients is limited. In this study, the authors evaluate the effects of frailty in geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm.

Methods: The authors conducted a retrospective cohort study of geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm between 2010 and 2017 by using the Nationwide Readmission Database. Demographics and frailty were queried at primary admission, and readmissions were analyzed at 30-, 90-, and 180-day intervals. Complications of interest included infection, anemia, infarction, kidney injury, CSF leak, urinary tract infection, and mortality. Nearest-neighbor propensity score matching for demographics was implemented to identify nonfrail control patients with similar diagnoses and procedures. The analysis used Welch two-sample t-tests for continuous variables and chi-square test with odds ratios.

Results: A total of 6713 frail patients and 6629 nonfrail patients were identified at primary admission. At primary admission, frail geriatric patients undergoing cranial neurosurgery had increased odds of developing acute posthemorrhagic anemia (OR 1.56, 95% CI 1.23-1.98; p = 0.00020); acute infection (OR 3.16, 95% CI 1.70-6.36; p = 0.00022); acute kidney injury (OR 1.32, 95% CI 1.07-1.62; p = 0.0088); urinary tract infection prior to discharge (OR 1.97, 95% CI 1.71-2.29; p < 0.0001); acute postoperative cerebral infarction (OR 1.57, 95% CI 1.17-2.11; p = 0.0026); and mortality (OR 1.64, 95% CI 1.22-2.24; p = 0.0012) compared to nonfrail geriatric patients receiving the same procedure. In addition, frail patients had a significantly increased inpatient length of stay (p < 0.0001) and all-payer hospital cost (p < 0.0001) compared to nonfrail patients at the time of primary admission. However, no significant difference was found between frail and nonfrail patients with regard to rates of infection, thromboembolism, CSF leak, dural tear, cerebral infarction, acute kidney injury, and mortality at all readmission time points.

Conclusions: Frailty may significantly increase the risks of short-term acute complications in geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm. Long-term analysis revealed no significant difference in complications between frail and nonfrail patients. Further research is warranted to understand the effects and timeline of frailty in geriatric patients.
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http://dx.doi.org/10.3171/2020.7.FOCUS20426DOI Listing
October 2020

Enhancing peripheral nerve regeneration with neurotrophic factors and bioengineered scaffolds: A basic science and clinical perspective.

J Peripher Nerv Syst 2020 12 23;25(4):320-334. Epub 2020 Sep 23.

Department of Neurological Surgery, University of California, San Diego, California, USA.

Despite the peripheral nervous systems (PNS) capacity to regenerate, functional restoration is highly variable following peripheral nerve injury (PNI), oftentimes leading to persistent functional deficits. In the preclinical arena, advances in the therapeutic use of exogenous neurotrophic factors and synthetic neural scaffold technology hold promise in augmenting endogenous PNS regeneration following PNI. Clinical trials utilizing neurotrophic factors for other indications (eg, peripheral neuropathy) may provide insight into their role in PNI. Here we provide an updated review of progress made toward enhancing regeneration after PNI with a focus on neurotrophic factors and bioengineered scaffolds.
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http://dx.doi.org/10.1111/jns.12414DOI Listing
December 2020

Staged Cranial Surgery for Intracranial Lesions: Historical Perspective.

World Neurosurg 2020 12 22;144:28-33. Epub 2020 Aug 22.

Department of Neurological Surgery, University of California, San Diego, La Jolla, California, USA.

We follow the development of staged resection from its first description by Walter E. Dandy, one of the founding fathers of neurosurgery, in 1925 in which he removed a large vestibular schwannoma.This historical vignette cites neurosurgical case reports and literature to demonstrate the evolution of staged resection of intracranial lesions, from Dandy's initial use to its becoming a more viable and safe option for the treatment of meningiomas, vestibular schwannomas, and skull base lesions (among numerous other intracranial pathologies). We also discuss the current advancements and future perspectives of staged resection that may show promise in effectively treating a wide range of pathologies while simultaneously reducing morbidity rates-a warrant for further exploration of staged cranial surgery as an important tool in neurosurgery.
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http://dx.doi.org/10.1016/j.wneu.2020.08.142DOI Listing
December 2020

James T. Goodrich, MD, PhD, 1946-2020: a historical perspective and his contributions to craniopagus separation.

J Neurosurg Pediatr 2020 Jun 19:1-7. Epub 2020 Jun 19.

5Department of Neurosurgery, UCI Health, School of Medicine, Irvine, California.

Dr. James Tait Goodrich was an internationally renowned pediatric neurosurgeon who pioneered the neurosurgical procedures for the multistage separation of craniopagus twins. As of March 2020, 59 craniopagus separations had been performed in the world, with Goodrich having performed 7 of these operations. He was the single most experienced surgeon in the field on this complex craniofacial disorder. Goodrich was a humble individual who rapidly rose through the ranks of academic neurosurgery, eventually serving as Director of the Division of Pediatric Neurosurgery at the Children's Hospital at Montefiore Medical Center in the Bronx, New York. In this historical vignette, the authors provide context into the history of and sociocultural attitudes toward conjoined twins; the epidemiology and classification of craniopagus twins; the beginnings of surgery in craniopagus twins; Goodrich's neurosurgical contributions toward advancing treatment for this complex craniofacial anomaly; and vignettes of Goodrich's unique clinical cases that made mainstream news coverage.
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http://dx.doi.org/10.3171/2020.5.PEDS20371DOI Listing
June 2020

Endoscopic Anterior Skull Base Reconstruction: A Meta-Analysis and Systematic Review of Graft Type.

World Neurosurg 2020 07 21;139:460-470. Epub 2020 Apr 21.

Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Irvine, California, USA; Department of Neurological Surgery, University of California Irvine, Irvine, California, USA. Electronic address:

Objective: The influence of graft type (nonautologous vs. autologous) on surgical outcomes in endoscopic anterior skull base (EASB) reconstruction is not well understood. This review systematically evaluated rates of postoperative complications of EASB repairs that utilized autologous or nonautologous grafts.

Methods: Original studies reporting EASB reconstruction outcomes were extracted from PubMed, Ovid, and the Cochrane Library from database inception to 2019. Risk ratios, risk differences, χ tests, and multivariate logistic regression were used to evaluate outcome measures: postoperative cerebrospinal fluid (CSF) leaks, meningitis, and other major complications (OMCs).

Results: A total of 2275 patients from 29 studies were analyzed. Rates of postoperative CSF leaks, meningitis, and OMCs were 4.0%, 1.6%, and 2.3%, respectively, using autologous grafts, and 5.0%, 0.3%, and 1.0%, respectively, using nonautologous grafts. Multivariate analysis of 118 patients demonstrated no significant differences in age, CSF flow rate, single or multilayer reconstruction, and presence of intraoperative CSF leak or lumbar drain. Meta-analyses of 6 studies yielded a risk ratio of 0.64 (95% confidence interval [CI], 0.19-2.14; P = 0.47) for postoperative CSF leakage, and risk differences of -0.01 (95% CI, -0.06 to 0.05; P = 0.80) and -0.02 (95% CI, -0.09 to 0.05; P = 0.51) for postoperative meningitis and OMCs, respectively. There were no significant differences in postoperative CSF leakage (P = 0.95) and OMCs (P = 0.41) between graft types among cases with intraoperative CSF leaks. However, meningitis rates were lower (P = 0.04) in the nonautologous group.

Conclusions: EASB reconstructions utilizing autologous and nonautologous grafts are associated with similar rates of postoperative CSF leakage and OMCs. In cases with intraoperative CSF leakage, nonautologous grafts were associated with reduced postoperative meningitis.
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http://dx.doi.org/10.1016/j.wneu.2020.04.089DOI Listing
July 2020

Spasm Freedom Following Microvascular Decompression for Hemifacial Spasm: Systematic Review and Meta-Analysis.

World Neurosurg 2020 07 16;139:e383-e390. Epub 2020 Apr 16.

Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.

Background: Hemifacial spasm (HFS) is a debilitating disorder characterized by intermittent involuntary movement of muscles innervated by the facial nerve. HFS is caused by neurovascular compression along the facial nerve root exit zone and can be treated by microvascular decompression (MVD). The goal was to determine rates and predictors of spasm freedom after MVD for HFS.

Methods: A literature search using the key terms "microvascular decompression" and "hemifacial spasm" was performed. The primary outcome variable was spasm freedom at last follow-up. Analysis was completed to evaluate for variables associated with spasm-free outcome.

Results: A total of 39 studies including 6249 patients were analyzed. Overall spasm freedom rate was 90.5% (5652/6249) at a follow-up of 1.25 ± 0.04 years. There was no significant relationship between spasm freedom versus persistent spasm and age at surgery, timing of follow-up, gender, disease duration, side of disease, or vessel type. Spasm freedom was more likely after an initial surgery versus a redo MVD (odds ratio 4.16, 95% confidence interval 1.99-8.68; P < 0.01).

Conclusions: MVD works well for HFS with cure rates >90% at 1-year follow-up in 6249 patients from 39 studies. A significant predictor of long-term spasm freedom at 1 year was an initial MVD as compared to repeat MVD. The majority of published manuscripts on MVD for HFS are heterogeneous single-institutional retrospective studies. As such, a large-scale meta-analysis reporting outcome rates and evaluating significant predictors of spasm freedom provides utility in the absence of randomized controlled studies.
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http://dx.doi.org/10.1016/j.wneu.2020.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899163PMC
July 2020

Peer-to-Peer Contact Tracing: Development of a Privacy-Preserving Smartphone App.

JMIR Mhealth Uhealth 2020 04 7;8(4):e18936. Epub 2020 Apr 7.

Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, United States.

Background: The novel coronavirus disease 2019 (COVID-19) pandemic is an urgent public health crisis, with epidemiologic models predicting severe consequences, including high death rates, if the virus is permitted to run its course without any intervention or response. Contact tracing using smartphone technology is a powerful tool that may be employed to limit disease transmission during an epidemic or pandemic; yet, contact tracing apps present significant privacy concerns regarding the collection of personal data such as location.

Objective: The aim of this study is to develop an effective contact tracing smartphone app that respects user privacy by not collecting location information or other personal data.

Methods: We propose the use of an anonymized graph of interpersonal interactions to conduct a novel form of contact tracing and have developed a proof-of-concept smartphone app that implements this approach. Additionally, we developed a computer simulation model that demonstrates the impact of our proposal on epidemic or pandemic outbreak trajectories across multiple rates of adoption.

Results: Our proof-of-concept smartphone app allows users to create "checkpoints" for contact tracing, check their risk level based on their past interactions, and anonymously self-report a positive status to their peer network. Our simulation results suggest that higher adoption rates of such an app may result in a better controlled epidemic or pandemic outbreak.

Conclusions: Our proposed smartphone-based contact tracing method presents a novel solution that preserves privacy while demonstrating the potential to suppress an epidemic or pandemic outbreak. This app could potentially be applied to the current COVID-19 pandemic as well as other epidemics or pandemics in the future to achieve a middle ground between drastic isolation measures and unmitigated disease spread.
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http://dx.doi.org/10.2196/18936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144575PMC
April 2020

False-Positive Cholesteatomas on Non-Echoplanar Diffusion-Weighted Magnetic Resonance Imaging.

Otol Neurotol 2020 06;41(5):e588-e592

Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery.

Objectives: To investigate false-positive findings on non-echoplanar (non-EPI) diffusion-weighted magnetic resonance imaging (DWI) in patients under surveillance post-cholesteatoma surgery.

Study Design, Setting, Subjects, And Methods: A retrospective review was performed on patients diagnosed with cholesteatoma who underwent surgical resection and were then followed by serial non-EPI DWI using half-Fourier acquisition single-shot turbo spin echo (HASTE) sequence. All patients had at least two annual follow-up imaging studies.

Results: False-positive findings were identified in four patients. The size of the suspected lesions was 4 to 12 mm. Otoendoscopy was used during all primary cases and Argon laser was used in one case. In all cases, the entire cholesteatoma was removed, and no residual disease was detected at the end of the procedures. One patient underwent revision surgery but only cartilage graft was found in the area of concern. All patients had stable or resolved hyperintense areas in the subsequent HASTE sequences.

Conclusion: False positive findings can occur with non-EPI DWI MRI and patients need to be counseled accordingly before revision surgery. Decreasing intensity and dimension of a suspected lesion and a positive finding in an area other than the location of the initial cholesteatoma may favor a false positive. If a false positive finding is suspected when the surgeon is confident of complete resection of the cholesteatoma, an MRI can be repeated in 6 to 12 months to assess changes in the dimension and intensity of the area of concern. Cartilage grafts may cause restricted diffusion on DWI sequences.
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http://dx.doi.org/10.1097/MAO.0000000000002606DOI Listing
June 2020

Impact of induction chemotherapy and socioeconomics on sinonasal undifferentiated carcinoma survival.

Int Forum Allergy Rhinol 2020 05 27;10(5):679-688. Epub 2020 Feb 27.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA.

Background: Sinonasal undifferentiated carcinoma (SNUC) is an uncommon malignancy of the nasal cavity and accessory sinuses with limited available studies evaluating role of induction chemotherapy (IC), demographics, and socioeconomic factors on overall survival (OS).

Methods: The 2004-2015 National Cancer Database was queried for patients with histologically confirmed SNUC. IC was defined as chemotherapy administered 6 months to 2 weeks before surgery or ≥45 days before radiotherapy.

Results: Of 440 identified patients, 70 (16%) underwent treatments involving IC. This consisted of 52 (12%), 15 (3%), and 3 (1%) patients receiving IC before definitive radiation therapy, surgery and adjuvant radiotherapy, or surgery only, respectively. On univariate analysis, IC (p = 0.34) did not affect OS, whereas having government insurance (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.37-2.34; p < 0.001) and living in regions with ≥13% of the population without a high school diploma (HR, 1.38; 95% CI, 1.06-1.79; p = 0.02) were associated with worse OS. On log-rank test, patients with advanced stage had similar OS regardless of whether or not they received IC (p = 0.96). Patients who received IC lived closer to their treatment site (p = 0.02) and had worse overall health, with more comorbidities (p = 0.02). The timing of IC before definitive surgery or radiation did not affect OS (p = 0.69).

Conclusion: In this SNUC population-based analysis, IC did not appear to provide additional OS benefit regardless of disease stage or timing before definitive treatment. Distance to treatment and level of comorbidities may be associated with receiving IC, whereas type of insurance and residence education level may impact SNUC OS, regardless of treatment.
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http://dx.doi.org/10.1002/alr.22536DOI Listing
May 2020

Noninvasive thermal evaluation for shunt failure in the emergency room.

Surg Neurol Int 2019 27;10:254. Epub 2019 Dec 27.

Department of Neurosurgery, University of California, Irvine Medical Center, Orange, California.

Background: Ventriculoperitoneal shunts (VPSs) have been the mainstay of treating hydrocephalus since the 1950s. However, shunts have a reported complication rate reaching nearly 50%. Devices have been developed that utilize noninvasive thermal transcutaneous diffusion technology. These shunt evaluation devices measure temperature gradients to detect shunt cerebrospinal fluid flow. We assessed the utility using a thermal diffusion technique to work up shunt failure in the emergency room (ER).

Methods: This was a retrospective case series at a single medical center ER. We included consecutive patients with possible VPS malfunction who were evaluated with a thermal sensor. The time period of data collection included September 2015-April 2018.

Results: Eight patients were reviewed, including four males and four females. The average age of reviewed patients was 35.1 (+/- ; 16.5). In our case series, three patients had adequate shunt flow as assessed by the shunt evaluation device, and the decision was made to discharge the patient and follow-up in clinic. In two patients, the flow was diminished, but due to other reassuring signs, the patients were still discharged with follow-up. Two patients were noted to have poor flow and were admitted for shunt revision.

Conclusion: It is important to determine whether a malfunction is present and whether an intervention is necessary for patients who present to the emergency department with possible symptoms of shunt failure. A thermal sensor is a fast and noninvasive tool in the evaluation of shunt flow and helps determine whether it is safe to send a patient home or intervene appropriately.
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http://dx.doi.org/10.25259/SNI_324_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935949PMC
December 2019

The Use of Imaging to Detect Intracranial Tumors in Idiopathic Olfactory Dysfunction: A Systematic Review.

Am J Rhinol Allergy 2020 Mar 20;34(2):297-305. Epub 2019 Nov 20.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California.

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http://dx.doi.org/10.1177/1945892419889325DOI Listing
March 2020

Efficacy of steroid-eluting stents in management of chronic rhinosinusitis after endoscopic sinus surgery: updated meta-analysis.

Int Forum Allergy Rhinol 2019 12 20;9(12):1443-1450. Epub 2019 Sep 20.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, CA.

Background: Recently, there has been mounting evidence suggesting the efficacy of steroid-eluting stents (SES) for management of chronic rhinosinusitis after endoscopic sinus surgery (ESS). This meta-analysis serves to evaluate the efficacy of SES in improving postoperative outcomes after ESS.

Methods: A systematic literature search was performed of PubMed for articles published between 1985 and 2018. The outcome variables were reported at, on average, 30 days postintervention.

Results: Seven of the 76 published studies, all of which were industry-sponsored, were included for a collective cohort of 444 SES and 444 control sinuses. In patients who received SES vs controls, collective odds ratios (ORs) for postoperative need for intervention, surgery, and oral steroid were 0.45 (95% confidence interval [CI], 0.33-0.62; p < 0.001), 0.30 (95% CI, 0.18-0.52; p < 0.001), and 0.58 (95% CI, 0.40-0.84; p = 0.004), respectively. In addition, collective ORs for frontal sinus ostia (FSO) patency, moderate-to-severe adhesion/scarring, and increase in polyp score were 2.53 (95% CI, 1.61-3.97; p < 0.001), 0.28 (95% CI, 0.13-0.59; p < 0.001), and 0.42 (95% CI, 0.25-0.74; p = 0.002), respectively. Collective mean differences for FSO/ethmoid inflammation and FSO diameter were -10.86 mm (p < 0.001) and +1.34 mm (p < 0.001), respectively.

Conclusion: Aggregate evidence suggests that SES can improve ESS outcomes by reducing rates of postoperative intervention and recurrent polyposis and inflammation, while promoting FSO patency. All included and analyzed studies were industry-sponsored and ruling-out publication bias was not possible. Future independent and nonsponsored studies to further evaluate SES's long-term efficacy are warranted.
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http://dx.doi.org/10.1002/alr.22443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6901756PMC
December 2019

Establishment and Benefits of a Normal Pressure Hydrocephalus Support Group on Patient Education and Experience.

Cureus 2019 Jun 26;11(6):e5007. Epub 2019 Jun 26.

Neurosurgery, University of California, Irvine Medical Center, Orange, USA.

Introduction: Normal pressure hydrocephalus (NPH) is a debilitating, neurological condition that can lead to mental deterioration. With the diagnosis and treatment of NPH constantly evolving and its symptoms worsening with age, education for patients and their families is crucial. In this study, we aim to explore the potential educational benefits of a physician-led NPH support group.

Methods: Between December 2015 and November 2018, six semiannual NPH support group meetings were held for patients and their families. Attendees, ages 20-90, completed a Likert scale-based survey designed to assess the support group's educational benefits using the following primary outcome variables: (1) subjective knowledge, (2) perceived utility/efficacy, and (3) patient satisfaction.

Results: Our survey data suggests that patients and their family members agree on the efficacy of the support group in learning about NPH. They felt that the support group served its purpose and improved their comfort/knowledge regarding NPH. There was consensus about sustaining and maintaining the support group for the future. Of 65 survey responses, the composite average score of questions pertaining to subjective knowledge, perceived utility/efficacy, and patient satisfaction was 4.5 out of 5.0.

Conclusion: We demonstrated that support groups are effective in educating the adult NPH population and their family/friends about NPH onset and treatment. Enhanced educational awareness for patients and families can help patients cope with their neurological condition and improve patient adherence to follow-up and physician recommendations.
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http://dx.doi.org/10.7759/cureus.5007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6713246PMC
June 2019

Visual and Endocrine Recovery Following Conservative and Surgical Treatment of Pituitary Apoplexy: A Meta-Analysis.

World Neurosurg 2019 Dec 27;132:33-40. Epub 2019 Aug 27.

Department of Neurological Surgery, University of California Irvine, Irvine, California, USA. Electronic address:

Background: Pituitary apoplexy (PA) can manifest with visual and endocrine defects. The literature lacks strong support for either surgical or conservative management with respect to symptomatic improvement of these deficits. This meta-analysis compared visual and endocrine outcomes in conservative and surgical treatment of PA.

Methods: A systematic literature search was performed in PubMed, Cochrane, and Ovid MEDLINE for articles published between 1988 and 2018. Recovery outcomes were binarized, such that complete and partial improvements were combined as "improvement." Primary outcome variables evaluated via a binary random-effects model were improvements in endocrine dysfunction, visual field and acuity deficits, and ophthalmoplegia or ocular nerve palsy.

Results: Of 483 published articles, 14 studies comprising 457 cases (259 surgical treatments and 198 conservative treatments) were included. On initial examination, 58% of patients had endocrine dysfunction, 37% had visual acuity or field deficit, and 47% had ophthalmoplegia or ocular nerve palsy. Evaluation of outcomes for surgically and conservatively treated patients yielded odds ratios of 0.609 (95% confidence interval [CI], 0.199-1.859; P = 0.383), 0.763 (95% CI, 0.307-2.374; P = 0.763), 1.167 (95% CI, 0.433-3.146; P = 0.760), and 0.801 (95% CI, 0.305-2.105; P = 0.653) for improvements in endocrine dysfunction, visual acuity dysfunction, visual field dysfunction, and ophthalmoplegia or ocular nerve palsy.

Conclusions: Both surgical intervention and conservative management of PA can lead to visual and endocrine recovery, although the management decision may heavily rely on severity of initial deficits. Treatment of PA can be multifaceted and tailored to the individual case and clinical judgment. Further investigation into appropriate intervention based on longitudinal outcome data is warranted.
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http://dx.doi.org/10.1016/j.wneu.2019.08.115DOI Listing
December 2019

Laser-Assisted Control of Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Systematic Review.

Lasers Surg Med 2020 04 22;52(4):293-300. Epub 2019 Aug 22.

Department of Otolaryngology-Head and Neck Surgery, University of California, 101 The City Dr. S., Bldg 56, Ste. 500, Orange, Irvine, CA, 92868.

Background And Objectives: Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, causes recurrent mucous membrane hemorrhage, especially epistaxis. In this systematic review, we discuss the efficacies of the three most common laser photocoagulation treatments for HHT-related epistaxis.

Study Design/materials And Methods: A systematic literature search was conducted in PubMed and MEDLINE from database inception to March 2019. Studies reporting epistaxis outcomes following argon, neodymium-doped yttrium aluminum garnet (Nd:YAG), and diode laser photocoagulation for HHT were included. χ and Barnard's exact tests were utilized to detect differences in reduced epistaxis frequency and intensity rates.

Results: Fifteen out of 157 published studies met our eligibility criteria, spanning a collective 362 patients. Argon, Nd:YAG, and diode laser therapy reduced epistaxis frequency in 90.4%, 88.9%, and 71.1% of patients, respectively, and reduced epistaxis intensity in 87.8%, 87.2%, and 71.1% of patients, respectively. Diode laser photocoagulation significantly underperformed in both outcome measurements when compared with argon (frequency: P = 0.005; intensity: P = 0.034) and Nd:YAG (frequency: P = 0.012; intensity: P = 0.041). There was no significant difference between argon and Nd:YAG in reducing HHT epistaxis frequency (P = 0.434) or intensity (P = 0.969). Categorizing HHT patients by clinical severity demonstrated a higher rate of improvement in the mild-moderate group compared with the severe group in both argon (P < 0.001) and Nd:YAG (P < 0.001) therapeutic methods. While no significant differences were found in rates of improved epistaxis outcomes between argon and Nd:YAG in mild-moderate HHT patients (frequency: P = 0.061; intensity: P = 0.061), Nd:YAG demonstrated greater rates of reduction in epistaxis frequency (P = 0.040) and intensity (P = 0.028) than argon among severe HHT patients.

Conclusions: HHT is a lifelong disease, plaguing patients with debilitating epistaxis. Intranasal laser photocoagulation of telangiectasias using argon or Nd:YAG laser therapy can yield improved epistaxis outcomes compared with diode laser photocoagulation. In severe cases of HHT, Nd:YAG laser therapy provides greater improvements in epistaxis outcomes than argon photocoagulation. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/lsm.23147DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035186PMC
April 2020