A unique approach to neurosurgical wound closure with porcine urinary bladder matrix: an illustrative case series.

INTRODUCTION: PUBM is a non-synthetic, completely resorbable xenograft product with a myriad of uses, including management of burns, acute and chronic wounds, soft tissue reinforcement, and hernia repair. The material is available in both powder and sheet forms which allows for excellent coverage of irregularly shaped wounds. CASE REPORT: The authors present 2 challenging neurosurgical wound cases. The first case is a large thoracolumbar wound secondary to a laminectomy complicated by a high output CSF fistula and dermal dehiscence. The second case is a deep postoperative surgical site infection in the setting of a large amount of surgical hardware. Both cases were successfully managed to complete wound healing with PUBM. CONCLUSION: Neurosurgical wounds can be technically challenging and difficult to manage. CSF fistulas lack evidence for standard treatment strategy, making complications and chronic wounds more likely. The application of PUBM in the closure of neurosurgical wounds has not been thoroughly studied and may lead to improved wound closure.

Novel Nerve-Sparing In Situ Assembly of an Expandable Titanium Cage to Maximize Endplate Coverage After Posterior Corpectomy for Comminuted Lumbar Burst Fractures.

BACKGROUND AND OBJECTIVES: The ability to maximize corpectomy cage endcap size and vertebral endplate coverage after corpectomy for lumbar burst fractures (L1-L5) is limited by the presence of lumbar nerve roots and the larger cross-sectional area of the lumbar endplates relative to the restrictive corridor for cage insertion. This work aims to provide details and clinical examples of a novel operative technique for 3-column reconstruction and stabilization of comminuted lumbar burst fractures. METHODS: Through a standard posterior midline approach and following posterior instrumentation and lateral extracavitary corpectomy, an in-situ assembly of a modular corpectomy cage that respects adjacent neural structures, restores segmental alignment, and maximizes endplate coverage across a lordotic segment is completed. RESULTS: Radiographic evidence of anatomic spinal reconstruction and stabilization with complete or near-complete endplate coverage without incurrence of new clinical deficit after this novel treatment of lumbar burst fractures. CONCLUSION: The fixation approach described in this report may be a valuable modification to a long-standing technique used for treating comminuted lumbar burst fractures (L1-L5) from a posterior-only approach without incurring additional neurological deficits and by improving endplate and apophyseal ring coverage.

Endoscopic neuroanatomy study using embalmed cadavers.

Objectives: A firm understanding of anatomy is foundational for all medical students and residents. As opportunities for cadaveric study dwindle, we propose a simplified perfusion model for formalin fixed cadavers that allow for endoscopic neuroanatomical study and procedural practice. This model is easily accessible, cost effective, and valuable in medical training. Materials and Methods: Cadavers were fixed through accepted methods that included formalin injection into the cranial vault. The perfusion system was set up using a series of catheters, tubing, and pressurized saline bag that forced saline into the various neuroanatomical spaces chosen for study. Results: A neuroendoscope was subsequently introduced to explore and identify relevant neuroanatomical structures as well as to perform a 3rd ventriculostomy and filum sectioning. Conclusion: Using formalin fixed cadavers for neuroendoscopic studies and procedural practice is a cost effective, multipurpose tool that can provide medical trainees with a strong understanding of anatomy as well as procedural practice.

Patient-Reported Outcomes and Provocative Testing in Peripheral Nerve Injury and Recovery.

Background Peripheral nerve function is often difficult to assess given the highly variable presentation and subjective patient experience of nerve injury. If nerve assessment is incomplete or inaccurate, inappropriate diagnosis and subsequent treatment may result in permanent dysfunction. Objective As our understanding of nerve repair and generation evolves, so have tools for evaluating peripheral nerve function, recovery, and nerve-related impact on the quality of life. Provocative testing is often used in the clinic to identify peripheral nerve dysfunction. Patient-reported outcome forms provide insights regarding the effect of nerve dysfunction on daily activities and quality of life. Methods We performed a review of the literature using a comprehensive combination of keywords and search algorithms to determine the clinical utility of different provocative tests and patient-reported outcomes measures in a variety of contexts, both pre- and postoperatively. Results This review may serve as a valuable resource for surgeons determining the appropriate provocative testing tools and patient-reported outcomes forms to monitor nerve function both pre- and postoperatively. Conclusion As treatments for peripheral nerve injury and dysfunction continue to improve, identifying the most appropriate measures of success may ultimately lead to improved patient outcomes.

Stoma Retraction in Super-Morbidly Obese Patient Leading to Class IV Midline Wound: A Cautionary Tale.

Stoma creation is often necessary for fecal diversion in general surgery. The creation of stomas involves mobilization of either the large or small intestine through the abdominal wall to allow for the passage of waste that traverses the intestinal tract. Among the complications of stoma creation, particularly in obese patients, is stoma retraction, whereby the stoma retracts greater than 5 mm from the skin. This is often accompanied by extensive dermal dehiscence, which can lead to significant leakage resulting in infection. Here, we present the case of a super-morbidly obese female patient with an end ileostomy following total colectomy in which abdominal closure was not initially achieved. The stoma became retracted and dehisced leading to continued contamination of the open abdomen, necessitating multiple abdominal washouts. Injection of 300 units of botulinum toxin A (BTA) was administered into the abdominal wall muscles later the day of her index operation. An Abdominal Wall Reapproximation Anchor (ABRA) dynamic tissue system (DTS) was utilized successfully in subsequent operations for primary myofascial closure. Heavy continuous contamination of the midline wound through the subcutaneous cleft between the retracted ileostomy and midline surgical wound was treated with intensive wound care, strict bed rest, nothing to eat or drink (NPO), and total parenteral nutrition (TPN). Post-operative stoma complications occur frequently, and stoma retraction is commonly encountered, especially in the obese. The patient presented in this case study had multiple risk factors which led to a complicated treatment course. Successful primary myofascial closure and complete healing of the midline surgical wound highlights the importance of a patient-tailored multimodal approach.

Association of Cerebellar Tonsil Dynamic Motion and Outcomes in Pediatric Chiari I Malformation.

OBJECTIVE: Chiari I malformation (CM-1), traditionally defined as a descent of the cerebellar tonsils by 5 mm or more, is surgically managed via posterior fossa decompression. However, there is currently no clear radiologic or symptomatic selection criteria for surgical intervention to indicate which patients may see the most improvement following decompression. METHODS: This retrospective pilot study included 22 patients who had symptomatic CM-1 managed via surgical decompression and 22 patients who had nonoperative management of CM-1. Tonsillar motion was assessed using phase-contrast magnetic resonance imaging and 2-dimensional fast imaging employing steady-state acquisition. Both quantitative and qualitative results that best described the CM-1 anatomy, radiologic measurements, and tonsillar motion were obtained and analyzed. RESULTS: Statistical analysis suggested that clinical symptoms differ based on tonsillar motion (P = 0.0044). Surgical patients had significantly more tonsillar motion than nonsurgical patients (P = 0.0010). Among the patients who underwent suboccipital decompression, the presurgery to postsurgery change in clinical symptoms was statistically significant (P < 0.0001), with all clinical symptoms showing decreased prevalence postsurgery. Anterior flow (P = 0.0004) and posterior flow (P < 0.0001) had significant negative associations with tonsillar motion. CONCLUSIONS: Tonsillar motion correlated positively with increased clinical symptoms of CM-1. Furthermore, tonsillar motion was associated with impaired cerebrospinal fluid flow that manifested in increased clinical symptoms. We recommend use of 2-dimensional fast imaging employing steady-state acquisition and assessment of cerebrospinal fluid flow as an adjunct to both clinical judgement and magnetic resonance imaging when selecting patients with CM-1 who would best benefit from surgical decompression.

Assessment of Motor Function in Peripheral Nerve Injury and Recovery.

Introduction: Peripheral nerve injuries can be difficult to diagnose, treat, and monitor given their highly variable presentation. When the status of nerves is not accurately assessed, treatment may be delayed or overlooked and can result in lasting functional deficits. As our understanding of nerve repair and generation evolves, so will tools for evaluating both the functional and morphological status of peripheral nerves. Objective: There is currently no single article which provides a detailed, comprehensive view of the literature comparing the clinical utility of various assessment modalities. Furthermore, there is no consensus on the optimal assessment algorithm for peripheral nerve injuries. Methods: We performed a literature review using a comprehensive combination of keywords and search algorithm. The search was focused on clinical data regarding the assessment of peripheral nerves Results: This review may help to determine the appropriate tools that are currently available for monitoring nerve function both pre and postoperatively. Additionally, the review demonstrates possible roles and areas of improvement for each tool used to assess motor function. Conclusion: As surgeons work to improve treatments for peripheral nerve injury and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.

Ectopic craniopharyngioma of the orbit: illustrative case.

BACKGROUND: Craniopharyngiomas are uncommon malformations of the sellar or parasellar region that are partly cystic and calcified and have low histological grade. The typical age of presentation is bimodal, with peak incidence rates in children at age 5 to 14 years and in adults at age 50 to 74 years. The usual clinical manifestations are related to endocrine deficiencies due to mass effect along with visual impairment and increased intracranial pressure. If a tumor is favorably localized, the treatment of choice is complete resection. OBSERVATIONS: The authors presented a unique case of a 61-year-old man with a suspicious cystic lesion in the right orbital roof that was causing right-sided headaches with pressure and pain in the right eye. Both computed tomography and magnetic resonance imaging were used for further evaluation and showed a suspicious lytic bone lesion that had an epicenter within the orbital rim, which was highly suggestive of a tumor of interosseous origin. After removal, the tumor was identified by pathology as a craniopharyngioma. LESSONS: The importance of this case report is in documenting a unique case of an ectopic craniopharyngioma in the orbit, adding to current hypotheses of the pathogenesis of ectopic craniopharyngiomas, and presenting an extensive review of literature.

Transoral digital reduction of complete anterior odontoid dislocation followed by fiducial-based navigated transcondylar screw fixation: illustrative case.

BACKGROUND: Posterior atlantoaxial dislocations (i.e., complete anterior odontoid dislocation) without C1 arch fractures are a rare hyperextension injury most often found in high-velocity trauma patients. Treatment options include either closed or open reduction and optional spinal fusion to address atlantoaxial instability due to ligamentous injury. OBSERVATIONS: A 60-year-old male was struck while on his bicycle by a truck and sustained an odontoid dislocation without C1 arch fracture. Imaging findings additionally delineated a high suspicion for craniocervical instability. The patient had neurological issues due to both a head injury and ischemia secondary to an injured vertebral artery. He was stabilized and transferred to our facility for definitive neurosurgical care. LESSONS: The patient underwent a successful transoral digital closed reduction and posterior occipital spinal fusion via a fiducial-based transcondylar, C1 lateral mass, C2 pedicle, and C3 lateral mass construct. This unique reduction technique has not been recorded in the literature before and avoided potential complications of overdistraction and the need for odontoidectomy. Furthermore, the use of bone fiducials for navigated screw fixation at the craniocervical junction is a novel technique and recommended particularly for placement of technically demanding transcondylar screws and C2 pedicle screws where pars anatomy is potentially unfavorable.

Clinical Assessment of Pain and Sensory Function in Peripheral Nerve Injury and Recovery: A Systematic Review of Literature.

Peripheral nerve injuries (PNIs) often present with variable symptoms, making them difficult to diagnose, treat, and monitor. When neurologic compromise is inadequately assessed, suboptimal treatment decisions can result in lasting functional deficits. There are many available tools for evaluating pain and functional status of peripheral nerves. However, the literature lacks a detailed, comprehensive view of the data comparing the clinical utility of these modalities, and there is no consensus on the optimal algorithm for sensory and pain assessment in PNIs. We performed a systematic review of the literature focused on clinical data, evaluating pain and sensory assessment methods in peripheral nerves. We searched through multiple databases, including PubMed/Medline, Embase, and Google Scholar, to identify studies that assessed assessment tools and explored their advantages and disadvantages. A total of 66 studies were selected that assessed various tools used to assess patient's pain and sensory recovery after a PNI. This review may serve as a guide to select the most appropriate assessment tools for monitoring nerve pain and/or sensory function both pre- and postoperatively. As the surgeons work to improve treatments for PNI and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.

Can healthy lifestyle reduce disease progression of Alzheimer's during a global pandemic of COVID-19?

The novel coronavirus disease 2019 (COVID-19) has pushed the medical system to its breaking point. While the virus does not discriminate, the elderly and those with comorbidities, including hypertension severe obesity, diabetes mellitus, coronary disease, pneumonia and dementia, are at a greater risk for adverse outcomes due to COVID-19. While many people navigate their new normal, the question of what the long-lasting effects of the pandemic may be, lingers. To investigate how vulnerable populations are affected by the pandemic, we focused on Alzheimer's disease, a vector to understanding how the virus has impacted AD progression and risk via aging. By assessing the effect of COVID-19 on AD patients, we explore genetics, metabolism, and lifestyle factors in both COVID-19 and Alzheimer's disease that can work synergistically to precipitate adverse outcomes. This article also discusses how age-related conditions and/or age-related comorbidities susceptible to COVID-19. We also discuss possible healthy lifestyle factors reduce and/or combat COVID-19 now and in the future.

The Emerging Role of HDACs: Pathology and Therapeutic Targets in Diabetes Mellitus.

Diabetes mellitus (DM) is one of the principal manifestations of metabolic syndrome and its prevalence with modern lifestyle is increasing incessantly. Chronic hyperglycemia can induce several vascular complications that were referred to be the major cause of morbidity and mortality in DM. Although several therapeutic targets have been identified and accessed clinically, the imminent risk of DM and its prevalence are still ascending. Substantial pieces of evidence revealed that histone deacetylase (HDAC) isoforms can regulate various molecular activities in DM via epigenetic and post-translational regulation of several transcription factors. To date, 18 HDAC isoforms have been identified in mammals that were categorized into four different classes. Classes I, II, and IV are regarded as classical HDACs, which operate through a Zn-based mechanism. In contrast, class III HDACs or Sirtuins depend on nicotinamide adenine dinucleotide (NAD+) for their molecular activity. Functionally, most of the HDAC isoforms can regulate ß cell fate, insulin release, insulin expression and signaling, and glucose metabolism. Moreover, the roles of HDAC members have been implicated in the regulation of oxidative stress, inflammation, apoptosis, fibrosis, and other pathological events, which substantially contribute to diabetes-related vascular dysfunctions. Therefore, HDACs could serve as the potential therapeutic target in DM towards developing novel intervention strategies. This review sheds light on the emerging role of HDACs/isoforms in diabetic pathophysiology and emphasized the scope of their targeting in DM for constituting novel interventional strategies for metabolic disorders/complications.

Implications of Age on Social Media Utilization in Health Care Practice Development: Cross-sectional Survey Study.

BACKGROUND: Medical practices, which are businesses through which one or more physicians treat patients, have likely not yet taken full advantage of the reach of social media. This study analyzed data collected using an anonymous survey to assess the potential utilization of large, established social media platforms in health care. The survey collected data from a diverse population of health care professional students, faculty, and physicians affiliated with the Texas Tech University Health Sciences Center (TTUHSC). This study provides significant, actionable data to more efficiently implement a social media strategy focused on age to help developing private practices and outpatient clinics from the perspective of those with experience in the field of medicine. OBJECTIVE: This cross-sectional, exploratory, descriptive study aims to explore the most effective strategies to use social media based on patient age to bring further success to a medical practice. METHODS: Data were gathered from an anonymous, peer-validated Qualtrics survey created by the corresponding authors based on the recommendations from a panel of experts including executive leadership at TTUHSC. The survey used a variety of question styles to measure differences between social media platforms, including frequency of use, current and future implications in medicine, and comfort in a health care setting. The sample population included students, interns, faculty, and physicians affiliated with the TTUHSC located throughout West Texas. RESULTS: The anonymous survey included 673 individuals from several different age groups predetermined at the beginning of the study. There were 154 respondents aged between 18 and 25 years, 171 aged between 26 and 35 years, 133 aged between 36 and 45 years, 104 aged between 46 and 55 years, and 111 aged between 56 and 89 years. The sample population also has a variety of educational achievements. The respondents were grouped based on the highest level of education attained, and this included 23.5% (n=158) of respondents who earned a high school diploma, 42% (n=283) who earned a bachelor's degree, 17.1% (n=115) who earned a master's degree, and 17.4% (n=117) who earned a doctorate degree. CONCLUSIONS: As social media continues to gain momentum, efficient utilization of the available platforms can help medical practices achieve larger patient populations and deliver more personalized care. However, privacy and security concerns should be considered while using social media in health care settings. Although this study demonstrated overwhelming interest in using social media in the medical field across all age groups, adoption willingness appears to be higher in younger respondents than in older respondents. Facebook was the most widely accepted social media platform in health care settings among all age groups. Nonetheless, other social media platforms could potentially be used more effectively depending on the age range of the targeted patient population.

Autophagy in the diabetic heart: A potential pharmacotherapeutic target in diabetic cardiomyopathy.

Association of diabetes with an elevated risk of cardiac failure has been clinically evident. Diabetes potentiates diastolic and systolic cardiac failure following the myocardial infarction that produces the cardiac muscle-specific microvascular complication, clinically termed as diabetic cardiomyopathy. Elevated susceptibility of diabetic cardiomyopathy is primarily caused by the generation of free radicals in the hyperglycemic milieu, compromising the myocardial contractility and normal cardiac functions with increasing redox insult, impaired mitochondria, damaged organelles, apoptosis, and cardiomyocytes fibrosis. Autophagy is essentially involved in the recycling/clearing the damaged organelles, cytoplasmic contents, and aggregates, which are frequently produced in cardiomyocytes. Although autophagy plays a vital role in maintaining the cellular homeostasis in diligent cardiac tissues, this process is frequently impaired in the diabetic heart. Given its clinical significance, accumulating evidence largely showed the functional aspects of autophagy in diabetic cardiomyopathy, elucidating its intricate protective and pathogenic outcomes. However, etiology and molecular readouts of these contrary autophagy activities in diabetic cardiomyopathy are not yet comprehensively assessed and translated. In this review, we attempted to assess the role of autophagy and its adaptations in the diabetic heart. To delineate the molecular consequences of these events, we provided detailed insights into the autophagy regulation pieces of machinery including the mTOR/AMPK, TFEB/ZNSCAN3, FOXOs, SIRTs, PINK1/Parkin, Nrf2, miRNAs, and others in the diabetic cardiomyopathy. Given the clinical significance of autophagy in the diabetic heart, we further discussed the potential pharmacotherapeutic strategies towards targeting autophagy. Taken together, the present report meticulously assessed autophagy, its adaptations, and molecular regulations in diabetic cardiomyopathy and reviewed the current autophagy-targeting strategies.

Fostering mesenchymal stem cell therapy to halt cytokine storm in COVID-19.

The coronavirus disease 2019 (COVID-19) has been threatening the globe since the end of November 2019. The disease revealed cracks in the health care system as health care providers across the world were left without guidelines on definitive usage of pharmaceutical agents or vaccines. The World Health Organization (WHO) declared COVID-19 as a pandemic on the 11th of March 2020. Individuals with underlying systemic disorders have reported complications, such as cytokine storms, when infected with the virus. As the number of positive cases and the death toll across the globe continue to rise, various researchers have turned to cell based therapy using stem cells to combat COVID-19. The field of stem cells and regenerative medicine has provided a paradigm shift in treating a disease with minimally invasive techniques that provides maximal clinical and functional outcome for patients. With the available evidence of immunomodulatory and immune-privilege actions, mesenchymal stem cells (MSCs) can repair, regenerate and remodulate the native homeostasis of pulmonary parenchyma with improved pulmonary compliance. This article revolves around the usage of novel MSCs therapy for combating COVID-19.

Synaptic basis of Alzheimer's disease: Focus on synaptic amyloid beta, P-tau and mitochondria.

Alzheimer's disease (AD) is a progressive and synaptic failure disease. Despite the many years of research, AD still harbors many secrets. As more of the world's population grows older, researchers are striving to find greater information on disease progression and pathogenesis. Identifying and treating the markers of this disease, or better yet, preventing it all together, are the hopes of those investing in this field of study. Several years of research revealed that synaptic pathology and mitochondrial oxidative damage are early events in disease progression. Loss of synapses and synaptic damage are the best correlates of cognitive deficits found in AD patients. As the disease progresses, there are significant changes at the synapse. These changes can both shed greater light onto the progression of the disease and serve as markers and therapeutic targets. This article addresses the mechanisms of synaptic action, mitochondrial regulation/dysregulation, resulting synaptic changes caused by amyloid beta and phosphorylated tau in AD progression. This article also highlights recent developments of risk factors, genetics and ApoE4 involvement, factors related to synaptic damage and loss, mislocalization of amyloid beta and phosphorylated tau, mitophagy, microglial activation and synapse-based therapies in AD. Furthermore, impairments in LTD and reactivation of microglia are discussed.

Current Status of Multiple Drug Molecules, and Vaccines: An Update in SARS-CoV-2 Therapeutics.

The coronavirus disease of 2019 (COVID-19) is a pandemic disease that has taken the lives of many around the world. It is caused by severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2). To date, the USA, Italy, Spain, France, Russia, and the UK have been hit the hardest by the virus. However, death counts are still rising. Some nations have managed to "flatten" the death rate via protective measures such physical distancing, quarantine measures, and therapeutic management. The structure of the SARS-CoV-2 virus comprises of S proteins, M proteins, E proteins, hemagglutinin esterases, nucleocapsid proteins, and a 30-kb RNA genome. Viral proteases cleave these polyproteins and RNA-dependent polymerases replicate the genome. Currently, there are no effective therapies against this new disease. Numerous investigators are developing novel protease inhibitors, some of which have made it into clinical trials. Researchers are also attempting to develop a vaccine. In this review paper, we discuss the latest therapeutic developments against COVID-19. Graphical Abstract.

SARS-CoV-2 pathophysiology and assessment of coronaviruses in CNS diseases with a focus on therapeutic targets.

The novel Coronavirus disease of 2019 (nCOV-19) is a viral outbreak noted first in Wuhan, China. This disease is caused by Severe Acute Respiratory Syndrome (SARS) Coronavirus (CoV)-2. In the past, other members of the coronavirus family, such as SARS and Middle East Respiratory Syndrome (MERS), have made an impact in China and the Arabian peninsula respectively. Both SARS and COVID-19 share similar symptoms such as fever, cough, and difficulty in breathing that can become fatal in later stages. However, SARS and MERS infections were epidemic diseases constrained to limited regions. By March 2020 the SARS-CoV-2 had spread across the globe and on March 11th, 2020 the World Health Organization (WHO) declared COVID-19 as pandemic disease. In severe SARS-CoV-2 infection, many patients succumbed to pneumonia. Higher rates of deaths were seen in older patients who had co-morbidities such as diabetes mellitus, hypertension, cardiovascular disease (CVD), and dementia. In this review paper, we discuss the effect of SARS-CoV-2 on CNS diseases, such as Alzheimer's-like dementia, and diabetes mellitus. We also focus on the virus genome, pathophysiology, theranostics, and autophagy mechanisms. We will assess the multiorgan failure reported in advanced stages of SARS-CoV-2 infection. Our paper will provide mechanistic clues and therapeutic targets for physicians and investigators to combat COVID-19.

Mitochondrial MicroRNAs in Aging and Neurodegenerative Diseases.

MicroRNAs (miRNAs) are important regulators of several biological processes, such as cell growth, cell proliferation, embryonic development, tissue differentiation, and apoptosis. Currently, over 2000 mammalian miRNAs have been reported to regulate these biological processes. A subset of microRNAs was found to be localized to human mitochondria (mitomiRs). Through years of research, over 400 mitomiRs have been shown to modulate the translational activity of the mitochondrial genome. While miRNAs have been studied for years, the function of mitomiRs and their role in neurodegenerative pathologies is not known. The purpose of our article is to highlight recent findings that relate mitomiRs to neurodegenerative diseases, including Alzheimer's, Parkinson's, and Huntington's. We also discuss the involvement of mitomiRs in regulating the mitochondrial genome in age-related neurodegenerative diseases.