Reproducible asystole following vagal nerve stimulator lead replacement: a case report.

BACKGROUND: Vagal nerve stimulation (VNS) is approved therapy for the treatment of intractable epilepsy. The stimulation of either nerve, left or right, is effective. However, due to the anatomic and physiological effects of cardiac innervation, the right vagus nerve is typically avoided in order to minimize the risk of cardiac bradyarrhythmias. The location of the VNS lead contacts on the nerve can also have an effect, namely, more distally placed contacts have been associated with lower risk of cardiac arrhythmias, presumably by avoiding vagal cervical cardiac branches; however, our case demonstrates reproducible asystole despite left sided, distal VNS lead placement. CASE PRESENTATION: We report a 28-year-old male patient with pharmacoresistant generalized clonic-tonic seizures. The VNS therapy with 1.5 mA output and 16% duty cycle drastically reduced his seizure burden for several years. The breakthrough seizures along with stabbing pain episodes at the implantable pulse generator (IPG) site have prompted the VNS lead revision surgery with new lead contacts placed more caudally than the old contacts. However, the intraoperative device interrogation with 1 mA output resulted in immediate asystole for the duration of stimulation and it was reproducible until the output was decreased to 0.675 mA. CONCLUSIONS: Our case highlights the possibility of new severe cardiac bradyarrhythmias following surgical VNS lead replacements even in patients without preoperatively known clinical side effects. We suggest preoperative electrocardiography and cardiology consultation for detected abnormalities for all patients undergoing new VNS implantations, as well as revision surgeries for VNS malfunctions. Intraoperatively, the surgeon and anesthesia team should be vigilant of cardiac rhythms and prepared for the immediate management.

Dr. Louise Eisenhardt's personal notes: how she and Dr. Cushing collected data and followed patients.

Dr. Louise Eisenhardt was one of the first neuropathologists and was responsible for the development of tumor diagnosis guidelines. This historical vignette reviews her previously unseen handwritten notes in which she describes methods used by her and Dr. Harvey Cushing to obtain patient follow-up data for their Brain Tumor Registry. Her description spans 50 years, using "every possible clue to be jumped upon in [their] clinical records and correspondence." Their follow-up was divided into two periods: early follow-up (1912-1932) and registry (1933-1961). During early follow-up, patients were asked to write to them on the anniversary of their operation. The foundation of the registry necessitated the use of "considerable effort on [their] part to gather up old threads" including renewed contact with patients after 15-20 years. Methods of follow-up included continued verbal and written correspondence with patients and "strong-arm methods," including use of the Fuller Brush man and the exhumation of a body. Drs. Eisenhardt and Cushing believed "every case was important in adding to our collective knowledge of various types of tumors particularly in relationship to life expectancies and suggesting improvement in surgical treatments." Dr. Eisenhardt's meticulous record keeping allows for insights into the first known outcomes-related tumor registry in neurosurgery.

A Functional Precision Medicine Pipeline Combines Comparative Transcriptomics and Tumor Organoid Modeling to Identify Bespoke Treatment Strategies for Glioblastoma.

Li Fraumeni syndrome (LFS) is a hereditary cancer predisposition syndrome caused by germline mutations in TP53. TP53 is the most common mutated gene in human cancer, occurring in 30-50% of glioblastomas (GBM). Here, we highlight a precision medicine platform to identify potential targets for a GBM patient with LFS. We used a comparative transcriptomics approach to identify genes that are uniquely overexpressed in the LFS GBM patient relative to a cancer compendium of 12,747 tumor RNA sequencing data sets, including 200 GBMs. STAT1 and STAT2 were identified as being significantly overexpressed in the LFS patient, indicating ruxolitinib, a Janus kinase 1 and 2 inhibitors, as a potential therapy. The LFS patient had the highest level of STAT1 and STAT2 expression in an institutional high-grade glioma cohort of 45 patients, further supporting the cancer compendium results. To empirically validate the comparative transcriptomics pipeline, we used a combination of adherent and organoid cell culture techniques, including ex vivo patient-derived organoids (PDOs) from four patient-derived cell lines, including the LFS patient. STAT1 and STAT2 expression levels in the four patient-derived cells correlated with levels identified in the respective parent tumors. In both adherent and organoid cultures, cells from the LFS patient were among the most sensitive to ruxolitinib compared to patient-derived cells with lower STAT1 and STAT2 expression levels. A spheroid-based drug screening assay (3D-PREDICT) was performed and used to identify further therapeutic targets. Two targeted therapies were selected for the patient of interest and resulted in radiographic disease stability. This manuscript supports the use of comparative transcriptomics to identify personalized therapeutic targets in a functional precision medicine platform for malignant brain tumors.

Surgical Treatment of Symptomatic Small Medial Petrous Meningiomas Causing Trigeminal Neuralgia.

BACKGROUND: Symptomatic trigeminal neuralgia caused by small (<3 cm) skull base meningiomas is treated by radiosurgery or surgical resection. Although radiosurgery is less invasive, surgical resection provides more rapid resolution of symptoms. We reviewed a short series of patients who underwent an anterior transpetrosal approach for surgical resection of meningiomas causing trigeminal neuralgia. METHODS: A retrospective review of 5 consecutive patients with meningiomas causing trigeminal neuralgia of the senior author was included. Preoperative parameters (size, proximity to critical neurovascular structures, presence of brainstem compression), intraoperative parameters (Simpson grade of resection, loss of brainstem evoked potentials, surgical approach), and outcomes (symptom resolution, extent of resection, follow-up) were recorded. RESULTS: Patient median age was 67 years (range, 60-73 years). All patients had symptoms concerning trigeminal neuralgia with 2 having associated areas of facial numbness. The anterior transpetrosal approach was used to achieve complete resection (Simpson grade I). Postresection, the trigeminal nerve and brainstem were clearly visible to evaluate neurovascular structures and ensure decompression. No postoperative complications were reported, and all patients experienced sustained symptomatic relief 1 month postsurgery. CONCLUSIONS: With the advent of radiosurgery for skull base meningiomas, surgical resection is not always considered; however, such meningiomas causing trigeminal neuralgia can be resected safely using the anterior transpetrosal approach allowing rapid resolution of symptoms. This review of operative nuances provides a guide for neurosurgeons to provide safe surgical resection.

Decompression of Cavernous Sinus for Trigeminal Neuropathic Pain From Perineural Spread of Tumor: 2-Dimensional Operative Video.

Head and neck malignancies with perineural spread are rare. Patients can present with neuropathic pain and cranial nerve palsies.1 Skull base approaches for surgical decompression are a consideration for patients to provide symptom relief.2 We demonstrate a frontotemporal extradural approach for a patient with worsening visual symptoms and refractory neuropathic pain in the V1, V2, and V3 distributions and briefly review the relevant anatomy.3-7 A 41-yr-old female with a poorly differentiated carcinoma of the head and neck with an infiltration of the cavernous sinus and perineural spread along the trigeminal nerve presented with severe neuropathic facial pain and anesthesia. She had previously undergone radiosurgery. Magnetic resonance imaging (MRI) demonstrated an interval increase in perineural disease within the cavernous sinus with extension intradurally. Her pain was medically refractory. A 2-dimensional intraoperative video illustrates the microsurgical decompression of her perineural invasion along the skull base as a palliative procedure. The patient recovered well postoperatively and had a symptomatic improvement in her pain and visual symptoms. Her preoperative facial numbness persisted postoperatively as expected. Postoperative imaging demonstrates a gross total resection of the intradural component of the tumor with decompression and expected expansion of the cavernous sinus. Because of the retrospective nature of this report, informed consent was not required. Images within the video have been reproduced from Fukuda et al4 with permission from © Georg Thieme Verlag KG; and Matsuo et al5 by permission of the Congress of Neurological Surgeons.

Assessment of impact of a skin cancer education session on cosmetology students' knowledge and preparedness to assess future clients for skin lesions.

BACKGROUND: Approximately 50% of cutaneous melanomas go undetected by patient self-inspection, and lesions that go unnoticed are usually located on the scalp, head, and neck. Cosmetologists are able to examine areas difficult to see on self-inspection. OBJECTIVES: The purpose of this study was to design and conduct an educational skin cancer screening presentation for cosmetology students and assess preparedness to discuss skin cancer with future clients. METHODS: This cross-sectional study conducted and analyzed in 2017 assessed the efficacy of a skin cancer education presentation among cosmetology students. Students completed a pre-/poststyle quiz aimed at assessing skin cancer knowledge. The difference in pre- and postknowledge quiz was analyzed using paired samples t test. RESULTS: A total of 194 students from seven cosmetology schools participated. Before the presentation, 43.4% felt underprepared to check for unusual lesions on future clients while 17.7% felt some level of preparedness. After, 3% felt underprepared while 51% felt prepared. There was a statistically significant difference in the skin cancer knowledge quiz total score before (M = 7.87, SD = 1.493) and after (M = 9.23, SD = 1.037) the educational presentation (P < 0.0001). CONCLUSIONS: This study shows most cosmetology students in the Tampa Bay area appear to be interested in learning more about skin cancer and agree that curricula should include skin cancer topics. Results of this study were limited to the Tampa Bay area and may not represent national trends. However, skin cancer presentation and screening-related content could be included in cosmetology curricula to help better prepare cosmetologists to screen for suspicious skin lesions.

Acute HIV Infection in a Patient with Repeat HIV Antibody/Antigen Negative Results Presenting at an Urban Emergency Department: A Case Report.

BACKGROUND: It is not uncommon for patients with human immunodeficiency virus (HIV) infections to visit the emergency department (ED) during seroconversion. However, patients with newly acquired HIV may not have a reactive screening result. We report a case of a patient who initially screened reactive on a fourth generation HIV test and subsequently nonreactive twice, but ultimately had positive viral load tests. CASE REPORT: A 41-year-old woman experiencing symptoms of a sore throat, odynophagia, and back and flank pain for 5 days presented to the ED. The patient had a reactive HIV screen but negative confirmatory antibody test. The ED provider ordered a HIV viral load, informed the patient, and discharged with oral antibacterial agent. The patient returned the next day and after review of Visit 1 results, the ED provider ordered a second HIV screen, which had a nonreactive result. Another HIV viral load order was placed. The patient was discharged and returned a third time, 4 days after initial presentation. On this visit she was admitted, and the initial HIV viral load result returned positive. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We report a case of a patient who initially screened reactive on a fourth generation HIV screening and then twice nonreactive on the same screening test, ultimately having positive viral loads. The most probable explanation for her series of atypical HIV results is that the patient presented during the p24 seroconversion window, which is graphically conveyed in Figure 1. If her first screening had been performed during the window, no further test would have been performed to rule out HIV, contributing to misdiagnosis. ED providers need to be aware that, at some time points during seroconversion from "negative" to "positive", patients recently infected with HIV and manifesting prodromal symptoms may nonetheless have a negative screening result.

Laser therapy for the treatment of pearly penile papules.

Pearly penile papules (PPP) present as dome-shaped papules of no more than 3 mm in diameter that line the base of the glans of the penis. These benign lesions affect between 14.3 and 48 % of men. While often asymptomatic, PPP can cause a great deal of psychological distress that may warrant treatment. Current treatment options include cryotherapy, electrodessication, and curettage (ED&C). However, these modalities may have considerable adverse cosmetic effects, including scarring, pain, and pigmentary changes. Laser modalities offer clear potential for improved cosmetic outcome in PPP treatment, but is not routinely used. Thus, a systematic review of available literature using the National Library of Medicine database PubMed was completed to find articles relevant to the treatment of PPP with laser and light therapy. The systematic search and screening of articles resulted in inclusion of eight articles discussing a total of 55 patients with PPP treated by laser therapy. The present systematic review found that erbium:yttrium-aluminum-garnet (Er:YAG) and CO2 laser were the most commonly reported (n = 45 and 7, respectively). Furthermore, the use of CO2, Er:YAG, pulsed dye laser, and fractional photothermolysis therapies demonstrated complete clearance of PPP in all cases with minimal complications and discomfort. Thus, based on the currently available evidence, laser therapy is a well-tolerated and efficacious method for treating PPP with minimal long-term adverse effects and a cosmetically desirable outcome. Although the included studies are limited in power, this systematic review offers clinically relevant insight into the potential for laser therapy.