Cerebral toxoplasmosis in a patient with combined variable immunodeficiency.

Background: Cerebral toxoplasmosis is an opportunistic infection in patients but has rarely been described in the setting of compromised humoral immunodeficiency. Prompt diagnosis and treatment of the infection is critical in the care of these patients. Medical management is the mainstay of treatment of the infection. There have been very few reports of surgical management of cerebral toxoplasmosis. Case Description: We describe the case of a 40-year-old male who presented with headache, memory deficits, weight loss, and left-sided weakness in the setting of a known but undiagnosed brain lesion identified 1 month prior. Imaging demonstrated a right basal ganglia lesion which was initially presumed to be malignancy. On further workup including a positive serum test and biopsy including polymerase chain reaction analysis, diagnosis was confirmed as toxoplasmosis. On further investigation, he was found to have deficiencies in immunoglobulins consistent with common variable immunodeficiency (CVID). The patient underwent craniotomy with surgical debulking as repeat imaging showed increased size of mass with new satellite lesions and worsening hydrocephalus. Conclusion: Cerebral toxoplasmosis is an important differential to consider in cases of intracerebral lesions and should not necessarily be excluded in the absence of compromised cellular immunity. In cases where there is no immunocompromised state and malignancy cannot immediately be established, CVID should be considered as an etiology. Due to the subtlety of CVID diagnosis, careful attention should be paid to history taking and workup for CVID should be considered as soon as possible. Surgical removal of these lesions in conjunction with medications is an effective treatment option.

Hawai'i Rural Health Program: Shaping the Next Generation of Rural Doctors.

Like many areas of the United States, Hawai'i and its rural communities are suffering from a significant physician shortage. The University of Hawai'i (UH) John A. Burns School of Medicine (JABSOM) developed the Hawai'i Rural Health Program (HRHP) in 2011 to help provide early and substantial rural training experiences for its medical students in hopes of generating more rural health care providers. Thus far, 20.6% of the students who participated in this program and have since graduated from residency are now practicing in rural communities. Final exam grades of students who participated in the program were not statistically different from those who did not participate, suggesting a similar quality of training between both the rural and traditional cohorts of students. Reflections from students who completed the program demonstrate the large and lasting impact that this immersive experience has on their medical education and desire to help rural communities.

Biopsy Artifact in Laser Interstitial Thermal Therapy: A Technical Note.

PURPOSE: The safety and effectiveness of laser interstitial thermal therapy (LITT) relies critically on the ability to continuously monitor the ablation based on real-time temperature mapping using magnetic resonance thermometry (MRT). This technique uses gradient recalled echo (GRE) sequences that are especially sensitive to susceptibility effects from air and blood. LITT for brain tumors is often preceded by a biopsy and is anecdotally associated with artifact during ablation. Thus, we reviewed our experience and describe the qualitative signal dropout that can interfere with ablation. METHODS: We retrospectively reviewed all LITT cases performed in our intraoperative MRI suite for tumors between 2017 and 2020. We identified a total of 17 LITT cases. Cases were reviewed for age, sex, pathology, presence of artifact, operative technique, and presence of blood/air on post-operative scans. RESULTS: We identified six cases that were preceded by biopsy, all six had artifact present during ablation, and all six were noted to have air/blood on their post-operative MRI or CT scans. In two of those cases, the artifactual signal dropout qualitatively interfered with thermal damage thresholds at the borders of the tumor. There was no artifact in the 11 non-biopsy cases and no obvious blood or air was noted on the post-ablation scans. CONCLUSION: Additional consideration should be given to pre-LITT biopsies. The presence of air/blood caused an artifactual signal dropout effect in cases with biopsy that was severe enough to interfere with ablation in a significant number of those cases. Additional studies are needed to identify modifying strategies.

Bone Marrow Aspirate in Spine Surgery: Case Series and Review of the Literature.

Background With the modernization of biotechnology, there has been a concerted effort to create novel biomaterials to promote arthrodesis for spine surgery. The novel use of the stem cells from bone marrow aspirate (BMA) to augment spine surgery is a burgeoning field because these cells are considered to be both osteoinductive and osteogenic. We sought to review the evidence behind the use of BMAs in spinal fusions and report the results of our own case series. Methods PubMed and EMBASE databases were searched for studies that investigated the use of stem cells for spine surgery. For our own case series, the medical records of 150 consecutive patients who underwent a lumbar spinal fusion with BMA were retrospectively reviewed for adverse events (AEs) for up to two years after surgery. Results In our case series, there were no AEs identified in 49% of our patients. Of the identified AEs, 61% were unrelated to the use of BMA (e.g., UTI and heart failure), with the remaining 39% likely unrelated to its use (e.g., back pain and anemia). There was a 92.8% arthrodesis rate with the use of BMA. Conclusions We reviewed the rationale, basic science, and clinical science for BMA usage in spine surgery and concluded that BMA is safe for use in spine surgery and is associated with a high rate of arthrodesis.