Risk of Neurological Decline in Patients With Temporal Lobe Brain Masses.

AIM: The objective of this study was to assess which clinical and radiographic findings may be associated with neurological decline in patients with temporal lobe mass lesions. PATIENTS AND METHODS: This represents a retrospective cohort study. Neurological decline was defined as a decline in Glasgow Coma Scale of 2 or more or new anisocoria. Adult patients aged 18 to 89 years with isolated temporal lobe, intra-axial, contrast-enhancing masses diagnosed between 1/1/2010 and 12/31/2020 were included. Clinical and radiographic findings were collected for each patient. Linear regression analysis was used to identify findings predictive of neurological decline. Patients with neurological decline were compared to stable patients to identify factors that may increase risk for neurological decline. RESULTS: A total of 71 patients met the inclusion criteria. Four out of the 71 patients experienced neurological decline, representing an incidence of 6%. Linear regression analysis identified only radiographic transtentorial herniation as a predictor of neurological decline (ß=0.26, p=0.03). A midline shift greater than 5 mm (100% vs. 40%; odds ratio=1.12, 95% confidence interval=1.00-1.32; p=0.05) and radiographic transtentorial herniation (75% vs. 18%; odds ratio=32.12, 95% confidence interval=3.91-264.18; p=0.03) were significantly more prevalent in patients with neurological decline and were associated with an increased risk of neurological decline. CONCLUSION: Radiographic transtentorial herniation and a midline shift greater than 5 mm may be useful findings to suggest an increased risk of neurological decline in patients with masses of the temporal lobe. This knowledge may be useful to neurosurgeons and physicians in other specialties to best care for this patient population.

Utility of 3-dimensionally printed models for parent education in pediatric plagiocephaly.

Objectives: Demonstrate the benefits of using 3D printed skull models when counseling families regarding disorders of the cranial vault (namely plagiocephaly and craniosynostosis), as traditional imaging review and discussion is often insufficient. Methods: 3D printed skull models of a patient with plagiocephaly were used during clinic appointments to aid in the counseling of parents. Surveys were distributed following the appointment to evaluate the utility of these models during the discussion. Results: Fifty surveys were distributed (with a 98% response rate). 3D models were both empirically and anecdotally helpful for parents in understanding their child's diagnosis. Conclusion: Advances in 3D printing technology and software have made producing models more accessible. Incorporating physical, disorder-specific models into our discussions has led to improvements in our ability to communicate with our patients and their families. Innovation: Disorders of the cranial can be challenging to describe to the parents and guardians of affected children; using 3D printed models is a useful adjunct in patient-centered discussions. The subject response to the use of these emerging technologies in this setting suggests a major role for 3D models in patient education and counseling for cranial vault disorders.

Growth hormone replacement therapy: is it safe to use in children with asymptomatic pituitary lesions?

OBJECTIVES: Small pituitary cysts are commonly discovered on pediatric brain magnetic resonance imagings (MRIs), particularly in patients with growth hormone deficiency (GHD). We examined the need for operative management in children with these masses as well as the effect of growth hormone replacement (GHR) on these lesions. METHODS: This was a retrospective review of pituitary protocol MRIs conducted in children 0-19 at a single center between April 2010-November 2020. Sex, indication for initial MRI, volume, and whether surgery was performed was determined. Records were reviewed to determine whether GHD was present and treatment with GHR documented. For patients with subsequent MRIs, volume on most recent scan was calculated. RESULTS: Of the 101 children with cysts, 25 had laboratory-confirmed GHD and 76 did not. GHD patients had a higher mean age compared to no growth hormone deficiency (NGHD) cohort (11.2 and 8.4 years, respectively; p=0.02) and a larger proportion of males (p<0.001). The mean cyst volume on initial MRI was not significantly smaller in patients with GHD (0.063 ± 0.012 cm3) vs. those without GHD (0.171 ± 0.039 cm3, p=0.11). Of the 21 GHD patients who received GHR and had follow-up MRIs, 10 had no change in pituitary cyst size, two had cysts that shrank, and seven disappeared. The remaining two cysts enlarged an average of 0.061 ± 0.033 cm3. Zero GHR recipients required surgical intervention. CONCLUSIONS: Small sellar cysts discovered incidentally on imaging in children are unlikely to require surgical intervention. GHR does not appear to significantly enlarge these pediatric pituitary lesions and is safe for use.

Shuntogram utility in predicting future shunt failures.

OBJECTIVE: Shunt failure remains a challenging diagnosis for neurosurgeons, particularly when patient symptoms suggest shunt malfunction but radiographic evidence is lacking. In such situations, shuntograms are sometimes employed to guide medical decision-making. In this study, the authors aimed to investigate the utility of shuntograms in aiding patient management, particularly in terms of a negative result. METHODS: This retrospective single-institution series comprises patients who underwent a shuntogram procedure to evaluate shunt patency over a roughly 6-year period. The medical records of patients were reviewed to determine the findings of the shuntogram procedure, the type of obstruction, and whether a subsequent operation for a shunt revision took place either within 30 days or up to 1 year after the procedure. Statistical analysis was completed by calculating the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the shuntogram as compared with the revision surgery. RESULTS: Of the 98 patients who underwent a shuntogram, 95 patients were included in the statistical analysis. A ventriculoperitoneal shunt was assessed in 81% of patients (77/95). The PPV of the procedure was 100%. The NPV for predicting a subsequent shunt revision within 30 days was 68.3% (false-negative rate of 31.7%) or within 365 days was 61.2% (false-negative rate of 38.8%). The sensitivity and specificity of the shuntogram were 55.8% and 100% within 30 days and 51.9% and 100% within 365 days, respectively. The most common intervention at the time of surgery following a negative shuntogram was a valve replacement in 38.5% of patients (10/26). CONCLUSIONS: With an NPV of 68.3% for predicting revision within 30 days in our series of 95 patients, shuntograms remained a useful tool in the clinical decision-making process when evaluating potential shunt failure.

Stabbing Injury of the Cervical Spinal Cord Resulting in Complete Loss of Bilateral Proprioception.

BACKGROUND: Direct penetrating trauma to the spinal cord as a result of stabbing is rare. The vertebral column is strongly suited to protecting the vital neural structures underneath, especially in the midline. CASE DESCRIPTION: A 25-year-old woman experienced a direct stabbing injury to her spinal cord, through the midline structures, resulting in bilateral dorsal column injury. She remained intact with regard to motor function despite bilateral sensory and proprioception loss. CONCLUSIONS: Owing to the strength of the protective elements of the osseous structures surrounding the spinal cord, direct stabbing injuries usually result in incomplete neurologic deficits. This is generally manifested as a Brown-Sequard syndrome because of the midline ligamentous structures and spinous processes deflecting injuries laterally. Our patient experienced a direct midline puncture, resulting in a unique case of bilateral dorsal column injury. These injuries are generally treated conservatively, in the absence of a retained foreign body. Spinal cord stabbing injuries are a rare entity with interesting clinical and anatomic correlations.

Cooperation between viral interferon regulatory factor 4 and RTA to activate a subset of Kaposi's sarcoma-associated herpesvirus lytic promoters.

The four Kaposi's sarcoma-associated herpesvirus (KSHV)-encoded interferon (IFN) regulatory factor homologues (vIRF1 to vIRF4) are used to counter innate immune defenses and suppress p53. The vIRF genes are arranged in tandem but differ in function and expression. In KSHV-infected effusion lymphoma lines, K10.5/vIRF3 and K11/vIRF2 mRNAs are readily detected during latency, whereas K9/vIRF1 and K10/vIRF4 mRNAs are upregulated during reactivation. Here we show that the K10/vIRF4 promoter responds to the lytic switch protein RTA in KSHV-infected cells but is essentially unresponsive in uninfected cells. Coexpression of RTA with vIRF4 is sufficient to restore regulation, a property not shared by other vIRFs. The K9/vIRF1 promoter behaves similarly, and production of infectious virus is enhanced by the presence of vIRF4. Synergy requires the DNA-binding domain (DBD) and C-terminal IRF homology regions of vIRF4. Mutations of arginine residues within the putative DNA recognition helix of vIRF4 or the invariant cysteines of the adjacent CxxC motif abolish cooperation with RTA, in the latter case by preventing self-association. The oligomerization and transactivation functions of RTA are also essential for synergy. The K10/vIRF4 promoter contains two transcription start sites (TSSs), and a 105-bp fragment containing the proximal promoter is responsive to vIRF4/RTA. Binding of a cellular factor(s) to this fragment is altered when both viral proteins are present, suggesting a possible mechanism for transcriptional synergy. Reliance on coregulators encoded by either the host or viral genome provides an elegant strategy for expanding the regulatory potential of a master regulator, such as RTA.

Measuring satisfaction with social work services.

For various reasons, the role of the medical social worker is often unclear to persons seeking medical treatment. Allied health professionals, such as nursing staff, tend to have a better understanding of the medical social worker's role and of whether services are being provided to best meet each patient's needs. We aimed to illustrate the abilities of nursing staff to provide patient satisfaction feedback to medical social workers in such areas as responsiveness to patient requests and the satisfaction of patients and their family members with the social services provided. Use of this satisfaction measurement technique will hopefully resolve any confusion that patients, and others not familiar with the role of the medical social worker, may have. This method provides accurate measurement of patients' evaluation of medical social work services.

Practical innovations: technology-assisted referrals.

Patients in the acute care setting often require referrals for post-hospital care. Before 2003, charts were copied manually and faxed to each nursing home separately, which was labor intensive, created delays, depended on legible notes, and did not ensure patient confidentiality. Social workers at our institution, in collaboration with 21 area nursing homes, successfully developed a program to streamline this process by using the electronic medical record and computer-assisted faxing. The patient's medical record (history/physical, nursing notes, pharmacy record, and therapy notes) was able to be transmitted quickly. This technology-assisted referral system had positive and successful outcomes, such as decreased length of stay, which resulted in an estimated cost savings of $2,008,512 per year.

Measuring productivity in medical social work.

Our purpose was to discuss the need for measuring and documenting social work services, as well as to discuss the data and statistical collection method used in Mayo Clinic's Section of Medical Social Services, which may be useful to other social service departments. The lack of empirical data showing the value of social work services may lead to decreases in staffing in medical social work departments. Mayo Clinic uses a computer application called MedSoc to gather case information and measure productivity, which is based on demand and capacity. Through use of MedSoc, our section improved communication among social work staff members and justified an increase in staffing of 38% from late 1997 to 2002.