The dumbest mistake I ever made.

Life as a Neurological Surgeon is a foreboding responsibility and a gratifying opportunity. Having the confidence and trust of individuals faced with a life or death situation requires extensive training and experience. Curiosity provides the motivation to continuously seek better understanding of complex disease problems, better technology, improved diagnostic capability, and surgical skills. Solution of these challenges has been a constant process for several decades and continues to pose opportunities for progress. Early observation of results provides important information, but in many circumstances it may require long-term evaluation to fully document the benefit, or lack of benefit, for any treatment procedure. The focus of attention by the Neurological Surgeon must be on the proper immediate management of each given situation, but it is also important, and a responsibility to consider the long-term consequences or results. This presents a difficult challenge because patients move into distant places and Neurological Surgeons frequently move to accept new opportunities. It is expensive and cumbersome to retain records for many years. It is also unpredictable which patient's information will become particularly significant. It is an opportunity to describe experience with four patients to illustrate this dilemma.

The roots of defense: plant resistance and tolerance to belowground herbivory.

BACKGROUND: There is conclusive evidence that there are fitness costs of plant defense and that herbivores can drive selection for defense. However, most work has focused on above-ground interactions, even though belowground herbivory may have greater impacts on individual plants than above-ground herbivory. Given the role of belowground plant structures in resource acquisition and storage, research on belowground herbivores has much to contribute to theories on the evolution of plant defense. Pocket gophers (Geomyidae) provide an excellent opportunity to study root herbivory. These subterranean rodents spend their entire lives belowground and specialize on consuming belowground plant parts. METHODOLOGY AND PRINCIPAL FINDINGS: We compared the root defenses of native forbs from mainland populations (with a history of gopher herbivory) to island populations (free from gophers for up to 500,000 years). Defense includes both resistance against herbivores and tolerance of herbivore damage. We used three approaches to compare these traits in island and mainland populations of two native California forbs: 1) Eschscholzia californica populations were assayed to compare alkaloid deterrents, 2) captive gophers were used to test the palatability of E. californica roots and 3) simulated root herbivory assessed tolerance to root damage in Deinandra fasciculata and E. californica. Mainland forms of E. californica contained 2.5 times greater concentration of alkaloids and were less palatable to gophers than island forms. Mainland forms of D. fasciculata and, to a lesser extent, E. californica were also more tolerant of root damage than island conspecifics. Interestingly, undamaged island individuals of D. fasciculata produced significantly more fruit than either damaged or undamaged mainland individuals. CONCLUSIONS AND SIGNIFICANCE: These results suggest that mainland plants are effective at deterring and tolerating pocket gopher herbivory. Results also suggest that both forms of defense are costly to fitness and thus reduced in the absence of the putative target herbivore.

Challenges and opportunities of open data in ecology.

Ecology is a synthetic discipline benefiting from open access to data from the earth, life, and social sciences. Technological challenges exist, however, due to the dispersed and heterogeneous nature of these data. Standardization of methods and development of robust metadata can increase data access but are not sufficient. Reproducibility of analyses is also important, and executable workflows are addressing this issue by capturing data provenance. Sociological challenges, including inadequate rewards for sharing data, must also be resolved. The establishment of well-curated, federated data repositories will provide a means to preserve data while promoting attribution and acknowledgement of its use.

Lies, damned lies, and statistics: a neurosurgical perspective on the international randomized trial of extracranial to intracranial arterial bypass surgery.

The abrupt occurrence of a devastating stroke has been referred to as "super death." It has long been realized that ischemic cerebral vascular disease may become symptomatic with a wide variety of clinical patterns. A robust circle of Willis has been recognized for its major protective function in many cases. When it became possible to actually create new collateral circulation to the brain by microsurgical techniques, significant enthusiasm arose. This enthusiasm was interrupted by the negative results of the international randomized trial. Further analysis of the trial raised serious questions regarding incomplete randomization by contributors to the study, and there remains uncertainty about important potential benefits for some individuals. Long-term follow-up of 3 patients having different and complex circumstances is described to emphasize this concern. After the creation of reliable collateral circulation to the brain, none has experienced new ischemic deficit during the subsequent follow-up of 27, 25, and 12 years, respectively.

Apparent competition with an exotic plant reduces native plant establishment.

Biological invasions can change ecosystem function, have tremendous economic costs, and impact human health; understanding the forces that cause and maintain biological invasions is thus of immediate importance. A mechanism by which exotic plants might displace native plants is by increasing the pressure of native consumers on native plants, a form of indirect interaction termed "apparent competition." Using experimental exclosures, seed addition, and monitoring of small mammals in a California grassland, we examined whether exotic Brassica nigra increases the pressure of native consumers on a native bunchgrass, Nassella pulchra. Experimental plots were weeded to focus entirely on indirect effects via consumers. We demonstrate that B. nigra alters the activity of native small-mammal consumers, creating a gradient of consumption that dramatically reduces N. pulchra establishment. Previous work has shown that N. pulchra is a strong competitor, but that it is heavily seed limited. By demonstrating that consumer pressure is sufficient to curtail establishment, our work provides a mechanism for this seed limitation and suggests that, despite being a good competitor, N. pulchra cannot reestablish close to B. nigra within its old habitats because exotic-mediated consumption preempts direct competitive exclusion. Moreover, we find that apparent competition has a spatial extent, suggesting that consumers may dictate the rate of invasion and the area available for restoration, and that nonspatial studies of apparent competition may miss important dynamics.

Thirty-year follow-up after extracranial-intracranial bypass surgery.

The conventional wisdom resulting from the international, multicenter, trial of extracranial-intracranial bypass surgery is that this procedure offers no benefit. Because of the complex and unique circumstances of some, clinical experience and judgment must sometimes overrule some statistical conclusions.

Costs and benefits of pocket gopher foraging: linking behavior and physiology.

Animals can attain fitness benefits by maintaining a positive net energy balance, including costs of movement during resource acquisition and the profits from foraging. Subterranean rodent burrowing provides an excellent system in which to examine the effects of movement costs on foraging behavior because it is energetically expensive to excavate burrows. We used an individual-based modeling approach to study pocket gopher foraging and its relationship to digging cost, food abundance, and food distribution. We used a unique combination of an individual-based foraging-behavior model and an energetic model to assess survival, body mass dynamics, and burrow configurations. Our model revealed that even the extreme cost of digging is not as costly as it appears when compared to metabolic costs. Concentrating digging in the area where food was found, or area-restricted search (ARS), was the most energetically efficient digging strategy compared to a random strategy. Field data show that natural burrow configurations were more closely approximated by the animals we modeled using ARS compared to random diggers. By using behavior and simple physiological principles in our model, we were able to observe realistic body mass dynamics and recreate natural movement patterns.

Invasion, competitive dominance, and resource use by exotic and native California grassland species.

The dynamics of invasive species may depend on their abilities to compete for resources and exploit disturbances relative to the abilities of native species. We test this hypothesis and explore its implications for the restoration of native ecosystems in one of the most dramatic ecological invasions worldwide, the replacement of native perennial grasses by exotic annual grasses and forbs in 9.2 million hectares of California grasslands. The long-term persistence of these exotic annuals has been thought to imply that the exotics are superior competitors. However, seed-addition experiments in a southern California grassland revealed that native perennial species, which had lower requirements for deep soil water, soil nitrate, and light, were strong competitors, and they markedly depressed the abundance and fecundity of exotic annuals after overcoming recruitment limitations. Native species reinvaded exotic grasslands across experimentally imposed nitrogen, water, and disturbance gradients. Thus, exotic annuals are not superior competitors but rather may dominate because of prior disturbance and the low dispersal abilities and extreme current rarity of native perennials. If our results prove to be general, it may be feasible to restore native California grassland flora to at least parts of its former range.

Physiology on a landscape scale: plant-animal interactions.

We explore in this paper how animals can be affected by variation in climate, topography, vegetation characteristics, and body size. We utilize new spatially explicit state-of-the-art models that incorporate principles from heat and mass transfer engineering, physiology, morphology, and behavior that have been modified to provide spatially explicit hypotheses using GIS. We demonstrate how temporal and spatial changes in microclimate resulting from differences in topography and vegetation cover alter animal energetics, and behavior. We explore the impacts of these energetic predictions on elk energetics in burned and unburned stands of conifer in winter in Yellowstone National Park, chuckwalla lizard distribution limits in North America, California Beechey Ground squirrel and Dusky Footed woodrat mass and energy requirements and activity patterns on the landscape, their predator prey interactions with a rattlesnake, Crotalus viridis, and shifts in that food web structure due to topographic and vegetative variation. We illustrate how different scales of data/observation provide different pieces of information that may collectively define the real distributions of a species. We then use sensitivity analyses of energetic models to evaluate hypotheses about the effects of changes in core temperature (fever) global climate (increased air temperature under a global warming scenario) and vegetation cover (deforestation) on winter survival of elk, the geographic distribution of chuckwallas and the activity overlap of predator and prey species within a subset of commonly observed species in a terrestrial food web. Variation in slope and aspect affect the spatial variance in solar radiation incident on the ground, hence ground surface temperature, at the same elevation, same hourly 2 m air temperatures, and wind speeds. We illustrate visually how spatial effects and landscape heterogeneity make statistical descriptions of animal responses problematic, since multiple distributions of their responses to climate, topography, and vegetation on the landscape can yield the same descriptive statistics, especially at high (30 m) resolution. This preliminary analysis suggests that the model has far-reaching implications for hypothesis testing in ecology at a variety of spatial and temporal scales.

Simulation models of the interactions between herbivore foraging strategies, social behavior, and plant community dynamics.

Herbivory often operates through a feedback in which herbivores affect the success and location of plants, which in turn affects the foraging behavior of animals. Factors other than food, such as social behavior, may influence the interactions between herbivores and the plants they consume. We used a simulation model to compare the effects of foraging and social behavior on plant distribution and foraging efficiency by gophers (Thomomys bottae) in a system characteristic of California grasslands. In this system, annual forbs are the preferred food items, and their abundance increases in areas disturbed by gopher burrowing. In addition, gopher social interactions generate buffer zones between adjacent burrows. During the first year of the simulations, before gophers affected the plant community, feeding efficiency declined with increased gopher density. However, after 40 yr, annual plant abundance increased with increasing gopher density, yielding higher maximum gopher density and per capita foraging efficiency. Conversely, increased width of the buffer zones lowered maximum gopher density and annual plant abundance resulting in lower feeding efficiency. In addition, the compact burrow structure of gophers employing an area-restricted search strategy allowed a higher density of gophers to coexist, resulting in higher annual plant abundance and higher per capita food-capture rates.

Retrieval of lost medial rectus muscles with a combined ophthalmologic and otolaryngologic surgical approach.

PURPOSE: To report retrieval of a medial rectus muscle completely detached from the globe and lost in the orbital tissue in four eyes. METHOD: A lost medial rectus muscle was retrieved in four eyes of four patients with either a transcutaneous medial orbitotomy approach or a transnasal endoscopic ethmoid sinus approach. RESULTS: The lost medial rectus muscle was successfully retrieved in all four patients. One patient lost the medial rectus muscle secondary to trauma, and the other three cases resulted from complications of strabismus surgery. The mean preoperative angle of exotropia was 44 prism diopters. The endoscopic approach was attempted in three patients, and the medial rectus muscle was successfully found in two of these patients. In one case in which the endoscopic approach was used, an image guidance system was used to aid in finding the lost medial rectus muscle. The endoscopic approach was abandoned in one case in which the medial rectus muscle could not be identified after extensive searching, but the muscle was subsequently found by means of the transcutaneous medial orbitotomy approach. A transcutaneous medial orbitotomy alone was used to find the lost medial rectus muscle in one of the cases. The postoperative ocular deviation for primary position at distance fixation was a mean of 24 prism diopters of exotropia. With one additional operation in two patients, the mean ocular deviation was less than 12 prism diopters. CONCLUSION: We successfully retrieved a lost medial rectus muscle in four patients with the use of nontraditional strabismus surgical techniques. We effectively combined techniques taken from both ophthalmology and otorhinolaryngology to help solve this difficult problem.

Immunolocalization of activated transforming growth factor beta1 in juvenile nasopharyngeal angiofibroma.

BACKGROUND: Juvenile nasopharyngeal angiofibroma (JNA) is a histologically benign, locally aggressive neoplasm of the nasopharynx that exclusively affects male adolescents. It is known to be sensitive to androgens, but there are likely intermediary cytokines and/or growth factors that mediate aggressive stromal cell proliferation and angiogenesis. Transforming growth factor beta1 (TGF-beta1) is a polypeptide that is secreted in an inactive form, cleaved to produce an active form, and then deactivated in the tissues. It activates fibroblast proliferation and is known to induce angiogenesis. OBJECTIVES: To evaluate the presence of activated TGF-beta1 within the stroma of JNA specimens and to quantify the percentage of JNA specimens expressing the active growth factor. DESIGN: Immunohistochemical analysis was performed on 19 specimens of JNA using a unique antibody that identifies only the activated form of TGF-beta1. The percentage of cells staining positively for activated TGF-beta1 was determined semiquantitatively by visual methods. RESULTS: Of 19 cases stained, all 19 (100%) showed strong positive staining (2 cases with 33%-66% of cells staining and 17 with 66%-100% of cells staining). Activated TGF-beta1 was identified in stromal cell nuclei and cytoplasm and in the endothelium of the capillaries within all specimens of JNA. CONCLUSIONS: The localization of activated TGF-beta1 to the fibroblasts and endothelial cells within JNA tumors suggests that TGF-beta1 may play a role in the stromal cell proliferation and angiogenesis associated with JNA. Additional receptor studies and more quantitative methods of analysis are needed to further define the role of TGF-beta1 in the pathogenesis of JNA.

The effect of hillslope angle on pocket gopher (Thomomys bottae) burrow geometry.

One way for animals to decrease energy expenditures is to minimize the cost of movement. For animals dwelling on slopes, gravity can impart a large energetic cost to movement. For this reason, animals traveling aboveground alter their movement patterns in response to the steepness of terrain (specifically hillslope angle) so as to minimize their energetic costs. Subterranean animals should also benefit from choosing optimum movement paths in relation to hillslopes but concurrently must factor the cost of excavation into their movement decisions. In cases where the excavation costs are much higher than the costs of working against gravity, excavation costs may override the consideration of gravitational costs and movement of subterranean animals may be independent of hillslope angle. To determine the response of a subterranean animal to hillslope angle, we excavated tunnels in the burrow systems of 19 pocket gophers in southern California that occupied hillslopes ranging from 2 to 30°. At each excavation we measured several characteristics of burrow geometry and used these data in a model of pocket gopher energetics to calculate the cost of tunnel construction at the various hillslope angles. We found that the cost of tunnel construction was independent of hillslope angle, and that the costs of shearing soil and pushing soil horizontally through the tunnels were 3 orders of magnitude greater than the costs of lifting the soil against the force of gravity. Accordingly, pocket gopher foraging tunnels were oriented independently of the hillslope. The decoupling of the movement patterns of subterranean animals from the effects of gravity is a distinctive feature of the subterranean habit compared to the movement of aboveground animals. Because of the important effects of tunnel construction on soil processes, this unique biological feature of subterranean animals has implications for basic physical processes, such as soil erosion. We found that the rate of soil flux generated by pocket gopher activity was invariant to hillslope. This relationship is in contrast to the most common model of soil movement generated by purely physical processes.

Optimal clip application and intraoperative angiography for intracranial aneurysms.

BACKGROUND: The actual incidence of residual aneurysm after clipping is unknown. The natural history of residual aneurysm can be regrowth and hemorrhage. Intraoperative angiography offers a cost-effective, safe interdiction to the problem of residual aneurysm and parent vessel stenosis. METHODS/RESULTS: Forty consecutive patients harboring 54 aneurysms underwent 42 operative procedures to clip 52 aneurysms, during which 220 intraoperative angiographic runs were performed. Ninety-three percent of the procedures were performed on patients with acute subarachnoid hemorrhage. There were 4 giant (>2.5 cm, 4/52 = 8%, all anterior circulation), 21 large (1.0-2.5 cm, 21/52 = 40%, 16/ 21 = 76% anterior circulation, 6/21 = 28% posterior circulation), and 27 small (<1.0 cm, 27/52-52%, 22/27 = 81% anterior circulation, 5/27 = 18% posterior circulation) aneurysms. Intraoperative angiography led to clip adjustment in 18/52 = 34% of aneurysms (4/18 = 22% for parent artery stenosis, 8/18 = 44% for residual aneurysm and 6/18 = 33% for both). Of the 18 adjustments made, 16 = 88% were made on giant or large aneurysms and two were small (one was a complex anterior communicating and one was a vertebral junction aneurysm). Follow-up angiography was performed on 26/42 = 62% of operative cases. Postoperative angiography confirmed intraoperative angiography in all cases. Two complications occurred during 220 angiographic runs: one embolic stroke and one incident of equipment failure. CONCLUSION: A grading scale was applied to test the relationship between anatomical site and size as they relate to the necessity for clip adjustment for complete aneurysm obliteration and/or parent artery compromise. Significance was related to site (basilar bifurcation, anterior communicating, middle cerebral bifurcation, and ophthalmic) and size (>1.0 cm), both as independent and codependent variables. An analysis of the cost-effectiveness of intraoperative angiography was demonstrated.

Subclavian pseudoaneurysm mimicking recurrent head and neck cancer.

Vascular blowouts are devastating complications of head and neck oncologic surgery that are easily diagnosed with oropharyngeal or external bleeding. We present herein a case of a pseudoaneurysm of the subclavian artery that mimicked recurrent head and neck carcinoma. Vascular lesions arising in the base of the neck may present with few signs of vascular injury. Head and neck surgeons should be aware of this unusual complication to avoid a potentially life-threatening event. We report difficulties in diagnosing subclavian pseudoaneurysm, a review of the vascular injuries related to this condition, as well as approaches to bleeding at the base of the neck.