Preoperative validation of edema-corrected tractography in neurosurgical practice: translating surgeon insights into novel software implementation.

Background: Peritumoral edema alters diffusion anisotropy, resulting in false negatives in tractography reconstructions negatively impacting surgical decision-making. With supratotal resections tied to survival benefit in glioma patients, advanced diffusion modeling is critical to visualize fibers within the peritumoral zone to prevent eloquent fiber transection thereafter. A preoperative assessment paradigm is therefore warranted to systematically evaluate multi-subject tractograms along clinically meaningful parameters. We propose a novel noninvasive surgically-focused survey to evaluate the benefits of a tractography algorithm for preoperative planning, subsequently applied to Synaptive Medical's free-water correction algorithm developed for clinically feasible single-shell DTI data. Methods: Ten neurosurgeons participated in the study and were presented with patient datasets containing histological lesions of varying degrees of edema. They were asked to compare standard (uncorrected) tractography reconstructions overlaid onto anatomical images with enhanced (corrected) reconstructions. The raters assessed the datasets in terms of overall data quality, tract alteration patterns, and the impact of the correction on lesion definition, brain-tumor interface, and optimal surgical pathway. Inter-rater reliability coefficients were calculated, and statistical comparisons were made. Results: Standard tractography was perceived as problematic in areas proximal to the lesion, presenting with significant tract reduction that challenged assessment of the brain-tumor interface and of tract infiltration. With correction applied, significant reduction in false negatives were reported along with additional insight into tract infiltration. Significant positive correlations were shown between favorable responses to the correction algorithm and the lesion-to-edema ratio, such that the correction offered further clarification in increasingly edematous and malignant lesions. Lastly, the correction was perceived to introduce false tracts in CSF spaces and - to a lesser degree - the grey-white matter interface, highlighting the need for noise mitigation. As a result, the algorithm was modified by free-water-parameterizing the tractography dataset and introducing a novel adaptive thresholding tool for customizable correction guided by the surgeon's discretion. Conclusion: Here we translate surgeon insights into a clinically deployable software implementation capable of recovering peritumoral tracts in edematous zones while mitigating artifacts through the introduction of a novel and adaptive case-specific correction tool. Together, these advances maximize tractography's clinical potential to personalize surgical decisions when faced with complex pathologies.

Improving the Management of Patients with Osteoporosis Undergoing Spinal Fusion: The Need for a Bone Mineral Density-Matched Interbody Cage.

With an increasingly aging population globally, a confluence has emerged between the rising prevalence of degenerative spinal disease and osteoporosis. Fusion of the anterior spinal column remains the mainstay surgical intervention for many spinal degenerative disorders. However, decreased vertebral bone mineral density (BMD), quantitatively measured by dual x-ray absorptiometry (DXA), complicates treatment with surgical interbody fusion as weak underlying bone stock increases the risk of post-operative implant-related adverse events, including cage subsidence. There is a necessity for developing cages with advanced structural designs that incorporate bioengineering and architectural principles to tailor the interbody fusion device directly to the patient's BMD status. Specifically, lattice-designed cages that mimic the web-like structure of native cancellous bone have demonstrated excellent resistance to post-operative subsidence. This article provides an introductory profile of a spinal interbody implant designed intentionally to simulate the lattice structure of human cancellous bone, with a similar modulus of elasticity, and specialized to match a patient's bone status across the BMD continuum. The implant incorporates an open pore design where the degree of pore compactness directly corresponds to the patient's DXA-defined BMD status, including patients with osteoporosis.

Effect of foster care on young children's language learning.

This report examines 174 young children's language outcomes in the Bucharest Early Intervention Project, the first randomized trial of foster placement after institutional care. Age of foster placement was highly correlated with language outcomes. Placement by 15 months led to similar expressive and receptive language test scores as typical age peers at 30 and 42 months. Placement from 15 to 24 months also led to dramatic language improvement. In contrast, children placed after 24 months had the same severe language delays as children in institutional care. Language samples at 42 months confirmed that placement after 24 months led to lower expressive skill.

Rarebit perimetry for bedside testing: comparison with standard automated perimetry.

BACKGROUND: Rarebit perimetry (RBP), a technique developed for the detection of early damage to the afferent visual system, has not been extensively tested at the bedside. This study was designed to test the feasibility of bedside testing with RBP in comparison with standard automated perimetry (SAP) performed in the clinic. METHODS: We tested 29 eyes of 15 subjects admitted with neurologic or neurosurgical diseases affecting the afferent visual system. RBP was performed on a laptop computer at the bedside. SAP (Humphrey field analyzer) testing was performed later in the clinic. Results were evaluated by a masked neuro-ophthalmologist. RESULTS: Visual fields corresponded between RBP and SAP in 21(72%) of the 29 tested eyes. RBP detected defects in 5 subjects who had normal visual field results on SAP. All subjects preferred RBP for convenience. CONCLUSION: RBP is a convenient method of bedside visual field testing and is no less sensitive to visual field defects in this role than SAP.

Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children randomized to foster vs ongoing institutional care.

OBJECTIVES: To determine effects of improved nurturing compared with institutional care on physical growth and to investigate the association between growth and cognitive development. DESIGN: A randomized controlled trial beginning in infants (mean age, 21.0 months; range, 5-32 months), with follow-up at 30, 42, and 54 months of age. SETTING: Institutionalized and community children in Bucharest, Romania. PARTICIPANTS: One hundred thirty-six healthy institutionalized children from 6 orphanages and 72 typically developing, never-institutionalized children. INTERVENTION: Institutionalized children were randomly assigned to receive foster care or institutional care as usual. OUTCOME MEASURES: Auxology and measures of intelligence over time. RESULTS: Growth in institutionalized children was compromised, particularly in infants weighing less than 2500 g at birth. Mean height and weight, though not head size, increased to near normal within 12 months in foster care. Significant independent predictors for greater catch-up in height and weight included age younger than 12 months at randomization, lower baseline z scores, and higher caregiving quality, particularly caregiver sensitivity and positive regard. Baseline developmental quotient, birth weight, and height catch-up were significant independent predictors of cognitive abilities at follow-up. Each incremental increase of 1 in standardized height scores between baseline and 42 months was associated with a mean increase of 12.6 points (SD, 4.7 points) in verbal IQ (P < .05). CONCLUSIONS: Foster care had a significant effect on growth, particularly with early placement and high-quality care. Growth and IQ in low-birth-weight children are particularly vulnerable to social deprivation. Catch-up growth in height under more nurturing conditions is a useful indicator of caregiving quality and cognitive improvement.

Language acquisition with limited input: Romanian institution and foster care.

PURPOSE: To provide the first detailed information about native language abilities of children who are or had been institutionalized. METHOD: The language of ten 30-month-old children raised in Romanian orphanages was compared with that of 30 chronological-age-matched peers: 10 children who had moved recently from orphanages to foster care, 10 children in foster families for at least 1 year, and 10 children raised in their biological families. Ten language measures were obtained from communication during play and from parent/caregiver report. RESULTS: Children who were institutionalized and children in foster care for a brief time showed substantial language delays, with some of these children not yet producing intelligible words. Children in foster care for at least 1 year approximated the expressive output and receptive language of children who had never been institutionalized; however, they showed lower expressive grammatical abilities. Within the group of children who were institutionalized, the presence of a preferred caregiver and a measure of development, greater height, were associated with greater language output. Although children in orphanages produced fewer complex forms than children in biological families, there were no systematic qualitative differences in language structure across groups. CONCLUSION: Foster care facilitated language growth after substantial language delays associated with institutionalization.

The caregiving context in institution-reared and family-reared infants and toddlers in Romania.

BACKGROUND: We assess individual differences in the caregiving environments of young children being raised in institutions in Romania in relation to developmental characteristics such as physical growth, cognitive development, emotional expression, and problem and competence behaviors. METHOD: Videotaped observations of the child and favorite caregiver in their 'home' environment were coded for caregiving quality, and this was related to child characteristics. Child emotional reactivity was assessed during responses to interactional tasks. Cognitive development was assessed from child responses to the Bayley Scales of Infant Development. Data regarding problem behaviors and competence were obtained from caregiver report. Children reared in institutions were compared on all of these measures to never institutionalized children to assist gauging degree of impairment. RESULTS: Children raised in institutions demonstrated marked delays in cognitive development, poorer physical growth, and marked deficits in competence. Individual differences in caregiving environment were associated with cognitive development, competence, and negative behavior among these young children being reared in institutions. CONCLUSIONS: These data confirm previous findings regarding deficits associated with institutional care and extend our understanding of the impact of individual differences in caregiving quality on the development of young children in institutions.

Ethical considerations in international research collaboration: The Bucharest early intervention project.

The Bucharest Early Intervention Project (BEIP) is the first ever randomized controlled trial of foster care as an alternative to institutional care for young children. It involved a collaboration between American investigators and Romanian health and child protection professionals. We present a brief description of the Romanian context and the project itself before discussing a number of ethical issues raised by the project. Organized around a discussion of exploitation, risk/benefit ratio, and cultural sensitivity, we evaluate a number of ethical issues involved in the BEIP using the Ethical Clinical Research Framework and the Fair Benefits Framework. Based on this review, we conclude that notwithstanding challenging ethical dilemmas, the benefits of the project outweighed its risks. Throughout the planning and implementation of the project, ethical issues were a central focus of discussion among the investigators and in the collaboration between Americans and Romanians. Thoughtful discussions from multiple perspectives are necessary to conduct research that is ethically sound and scientifically meaningful.

Attachment in institutionalized and community children in Romania.

This study examined attachment in institutionalized and community children 12-31 months of age in Bucharest, Romania. Attachment was assessed using ratings of attachment behaviors and ratings of caregiver descriptions in a structured interview. As predicted, children raised in institutions exhibited serious disturbances of attachment as assessed by all methods. Observed quality of caregiving was related to formation and organization of attachment in children living in institutions. These results held even when other variables, such as cognitive level, perceived competence, and quantitative interaction ratings, were controlled for. Ratings of attachment behavior in the Strange Situation and caregiver reports of signs of Reactive Attachment Disorder converged moderately. The implications of these findings for different perspectives on attachment are discussed.