Contrast enhancing epidural fluid accumulation after percutaneous endoscopic lumbar discectomy: A case report of recurrent disc herniation within pseudocyst secondary to irrigation fluid.

INTRODUCTION: Percutaneous endoscopic lumbar discectomy (PELD) is increasingly being utilized to treat patients with lumbar disc herniation. PELD is unique in that it uses a single working port endoscope with constant irrigation of the surgical field to visualize pathology. The current report is of a case of postoperative epidural irrigation fluid accumulation presenting as peripherally enhancing epidural lesions, masking an underlying re-herniation. PRESENTATION OF CASE: A patient with a Lumbar 5-Sacral 1 level disc herniation presenting with radiculopathy was treated using PELD. Following the operation, the patient experienced recurrent pain, prompting a repeat MRI of the lumbar spine. Multiple ring-enhancing lesions within the epidural space were observed, creating diagnostic dilemmas. The differential diagnoses included epidural abscess, pseudomeningocele from unintended durotomy, epidural hematoma, or trapped epidural fluid collection presenting as a pseudocyst with or without recurrent disc herniation. A repeat endoscopic discectomy was performed to confirm the diagnosis of pseudocyst, revealing a recurrent disc herniation. DISCUSSION: Pseudocysts are not an uncommon complication of PELD, typically believed to be due to an inflammatory response to disc fragments. However, in this case, the epidural fluid collection was likely the result of trapped irrigation fluid from continuous irrigation during the procedure, which masked an underlying re-herniation on imaging. CONCLUSION: With the increasing utilization of PELD, it is important to acknowledge unique complications such as fluid accumulation from irrigation within the epidural space. Fluid accumulation can lead to contrast-enhancing pseudocyst formation, which can theoretically lead to mass effect or increased intracranial and intraspinal pressure and may mask additional underlying pathology.

Vacuum-assisted scalp repositioning: a novel temporizing approach to acute sinking skin flap syndrome. Illustrative cases.

BACKGROUND: This report describes the use of a novel approach to address acute sinking skin flap syndrome (SSFS), a postcraniectomy complication arising from brain dysfunction beneath the skull defect. The authors present a case series of two patients, emphasizing the prospective application of an external plaster cast in tandem with a vacuum-assisted closure (VAC) device (wound VAC) to promptly reposition the scalp and relieve brain compression. OBSERVATIONS: Following intervention, one patient showed immediate neurological improvement, with complete resolution of symptoms within hours. Conversely, the second patient developed nonconvulsive status epilepticus. Computed tomography scans postintervention validated the successful scalp repositioning and mass effect resolution in both instances. This temporary approach proved successful in one patient with moderate symptoms, serving as a bridge to cranioplasty. LESSONS: The integration of an external plaster cast and wound VAC offers a cost-effective and prompt solution for patients with acute SSFS pending cranioplasty. Appropriate patient selection and heightened caution for those with severe symptoms should be exercised.

Endoscopic and Nonendoscopic Approaches to Single-Level Lumbar Spine Decompression: Propensity Score-Matched Comparative Analysis and Frailty-Driven Predictive Model.

OBJECTIVE: The endoscopic spine surgery (ESS) approach is associated with high levels of patient satisfaction, shorter recovery time, and reduced complications. The present study reports multicenter, international data, comparing ESS and non-ESS approaches for singlelevel lumbar decompression, and proposes a frailty-driven predictive model for nonhome discharge (NHD) disposition. METHODS: Cases of ESS and non-ESS lumbar spine decompression were queried from the American College of Surgeons National Surgical Quality Improvement Program database (2017-2020). Propensity score matching was performed on baseline characteristics frailty score (measured by risk analysis index [RAI] and modified frailty index-5 [mFI-5]). The primary outcome of interest was NHD disposition. A predictive model was built using logistic regression with RAI as the primary driver. RESULTS: Single-level nonfusion spine lumbar decompression surgery was performed in 38,686 patients. Frailty, as measured by RAI, was a reliable predictor of NHD with excellent discriminatory accuracy in receiver operating characteristic (ROC) curve analysis: C-statistic: 0.80 (95% confidence interval [CI], 0.65-0.94) in ESS cohort, C-statistic: 0.75 (95% CI, 0.73-0.76) overall cohort. After propensity score matching, there was a reduction in total operative time (89 minutes vs. 103 minutes, p = 0.049) and hospital length of stay (LOS) (0.82 days vs. 1.37 days, p < 0.001) in patients treated endoscopically. In ROC curve analysis, the frailty-driven predictive model performed with excellent diagnostic accuracy for the primary outcome of NHD (C-statistic: 0.87; 95% CI, 0.85-0.88). CONCLUSION: After frailty-based propensity matching, ESS is associated with reduced operative time, shorter hospital LOS, and decreased NHD. The RAI frailty-driven model predicts NHD with excellent diagnostic accuracy and may be applied to preoperative decisionmaking with a user-friendly calculator: nsgyfrailtyoutcomeslab.shinyapps.io/lumbar_decompression_dischargedispo.

Projecting Informal Care Demand among Older Koreans between 2020 and 2067.

BACKGROUND: The number of Korean older people receiving informal care is expected to rise sharply due to aging population. This study makes projections of demand for informal care in community-dwelling older people aged 65 and over in Korea until 2067. METHOD: The study drew on data collected from waves 4-6 of the Korean Longitudinal Study of Aging (2012-2016, n = 12,975). Population data published by Statistics Korea and data from the Long-term Care Insurance Statistical Yearbook for Korea were also used. A macro-simulation model was built to make the projections. RESULTS: The number of older people receiving informal care will increase from 0.71 million in 2020 to 2.2 million in 2067. Demand for informal care from adult children or relatives is projected to rise by 257%, much faster than the increase in demand for spousal care (164%). The estimates are sensitive to alternative assumptions about future mortality rates, fertility rates, patterns of migration, and the prevalence of functional disabilities in the population. CONCLUSION: Demand for informal care in Korea will rise substantially in the coming decades, and the increase will be uneven for different groups of care users. Our analyses are not only relevant to the long-term care system for the general older population but also have profound implications for intensive users of long-term care in Korea. The findings highlight the importance of accurate identification of unmet needs in the population and timely delivery of government support to older people and their informal caregivers.

Frailty Status Is a More Robust Predictor Than Age of Spinal Tumor Surgery Outcomes: A NSQIP Analysis of 4,662 Patients.

OBJECTIVE: The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry. METHODS: The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients' data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5. RESULTS: Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. 'Severely frail' patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21-35.44) for 30-day mortality, 3.02 (95% CI, 1.97-4.56) for major complications, and 2.94 (95% CI, 2.32-4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality. CONCLUSION: Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.

Decision-making for decompressive craniectomy in traumatic brain injury aided by multimodality monitoring: illustrative case.

BACKGROUND: Severe traumatic brain injury (TBI) requires individualized, physiology-based management to avoid secondary brain injury. Recent improvements in quantitative assessments of metabolism, oxygenation, and subtle examination changes may potentially allow for more targeted, rational approaches beyond simple intracranial pressure (ICP)-based management. The authors present a case in which multimodality monitoring assisted in decision-making for decompressive craniectomy. OBSERVATIONS: This patient sustained a severe TBI without mass lesion and was monitored with a multimodality approach. Although imaging did not seem grossly worrisome, ICP, pressure reactivity, brain tissue oxygenation, and pupillary response all began worsening, pushing toward decompressive craniectomy. All parameters normalized after decompression, and the patient had a satisfactory clinical outcome. LESSONS: Given recent conflicting randomized trials on the utility of decompressive craniectomy in severe TBI, precision, physiology-based approaches may offer an improved strategy to determine who is most likely to benefit from aggressive treatment. Trials are underway to test components of these strategies.

Lumbar Annular High-Intensity Zone as a Precursor to Disc Extrusion.

Low back pain (LBP) is a common affliction with numerous causes. Some individuals experience LBP attributed to disc pathology. Disc pathology has been implicated in a plurality of cases of LBP, and some cases are associated with annular fissures (AFs). AFs are weaknesses in the structure that contains the nucleus pulposus and is the site of possible disc herniations. On magnetic resonance imaging (MRI), some AFs manifest as the high-intensity zone (HIZ), otherwise known as an annular enhancement region. In this report, we present three patients with LBP, mild radiculitis, and HIZ who later developed herniated nucleus pulposus (HNP) with extrusion through the HIZ. These cases suggest that HIZ indicates a propensity for the future development of disc extrusion through the weakened tissue at the AF visualized as HIZ on MRI. With a better understanding of the association between AFs and disc herniations with HIZ, clinicians may be able to predict and prevent the pain and disability associated with disc extrusion.

Endoscopic Transforaminal Drainage of a Ventrally Located Thoracic Epidural Abscess.

BACKGROUND: No formalized surgical treatment strategy exists for a thoracic epidural abscess. Although endoscopic approaches have been described for the treatment of spinal infections, this is the first report of an endoscopic transforaminal approach for the drainage of a thoracic/lumbar epidural abscess with placement of indwelling abscess drain. We present a novel use of a known endoscopic approach and describe a minimally invasive surgical option for ventrally located thoracic epidural abscesses. CASE DESCRIPTION: A patient with ventrally located T5-L5 epidural abscess with cord compression was taken for endoscopic transforaminal drainage at the right T9-10 level. A drain was left in the abscess cavity and tunneled subcutaneously for continued postoperative drainage. Immediate postoperative radiographic results showed significant reduction in the abscess size. The patient tolerated the procedure well with return to neurologic baseline. CONCLUSIONS: Endoscopic transforaminal drainage of ventrally located thoracic epidural abscess is a safe procedure that may be an option for patients with a purulent-filled abscess. This procedure should be considered an option to avoid more invasive procedures that would require decompression and possibly instrumented fusion.

Kinetic Modeling of Hyperpolarized Carbon-13 Pyruvate Metabolism in the Human Brain.

Kinetic modeling of the in vivo pyruvate-to-lactate conversion is crucial to investigating aberrant cancer metabolism that demonstrates Warburg effect modifications. Non-invasive detection of alterations to metabolic flux might offer prognostic value and improve the monitoring of response to treatment. In this clinical research project, hyperpolarized [1-13C] pyruvate was intravenously injected in a total of 10 brain tumor patients to measure its rate of conversion to lactate ( kPL ) and bicarbonate ( kPB ) via echo-planar imaging. Our aim was to investigate new methods to provide kPL and kPB maps with whole-brain coverage. The approach was data-driven and addressed two main issues: selecting the optimal model for fitting our data and determining an appropriate goodness-of-fit metric. The statistical analysis suggested that an input-less model had the best agreement with the data. It was also found that selecting voxels based on post-fitting error criteria provided improved precision and wider spatial coverage compared to using signal-to-noise cutoffs alone.

First hyperpolarized [2-13C]pyruvate MR studies of human brain metabolism.

We developed methods for the preparation of hyperpolarized (HP) sterile [2-13C]pyruvate to test its feasibility in first-ever human NMR studies following FDA-IND & IRB approval. Spectral results using this MR stable-isotope imaging approach demonstrated the feasibility of investigating human cerebral energy metabolism by measuring the dynamic conversion of HP [2-13C]pyruvate to [2-13C]lactate and [5-13C]glutamate in the brain of four healthy volunteers. Metabolite kinetics, signal-to-noise (SNR) and area-under-curve (AUC) ratios, and calculated [2-13C]pyruvate to [2-13C]lactate conversion rates (kPL) were measured and showed similar but not identical inter-subject values. The kPL measurements were equivalent with prior human HP [1-13C]pyruvate measurements.

Community Health Centers: a Key Partner to Achieve Medicaid Expansion.

Medicaid expansion is an important feature of the "Affordable Care Act" and also is proposed as a component of some incremental plans for universal healthcare coverage. We describe (1) obstacles encountered with Medicaid coverage, (2) their potential resolution by federally qualified community health centers (CHCs), (3) the current status and limitations of CHCs, and (4) a proposed mega CHC model which could help assure access to care under Medicaid coverage expansion. Proposed development of the mega CHC model involves a three-component system featuring (1) satellite neighborhood outreach clinics, with team care directed by primary care nurse practitioners, (2) a hub central CHC which would closely correspond to the logistics and administration of current CHCs, and (3) a teaching hospital facilitating subspecialty care for CHC patients, with high-quality and cost-effectiveness. We believe that this new model, designated as a mega CHC, will demonstrate that CHCs can achieve their potential as a key partner to insure care under Medicaid expansion.

Re-excision rate after sector resection for breast cancer: A 5-year retrospective cohort study.

BACKGROUND: Positive margins after Breast conserving surgery (BCS) for breast cancer can result in local recurrence (LR) requiring further surgery. This can lead to unnecessary patient anxiety, poor prognosis and impose additional economic burden to our health system. The aim of this study is to assess the rate of re-excision for positive margins after BCS using the sector resection technique. METHODS: This single centre retrospective cohort study included all women who underwent BCS using sector resection between the years of 2012 and 2016. A total of 456 patients underwent sector resection. We evaluated the margin status, re-excision rates and their predictive risk factors. RESULTS: 415 (91%) patients had clear margins. 41 (9%) patients underwent further re-excision for positive or close margin. 75.6% of those patients had DCIS and 51% had invasive carcinoma involving the margins. Patient and tumour characteristics associated with an increased risk of positive margin were women under the age of 50 (p = 0.19), tumours >50 mm (p = 0.001), grade-2 (p = 0.48) and grade-3 (p = 0.63), HER-2 positivity (p = 0.02), sentinel lymph node positivity (p = 0.03), and patients undergoing axillary lymph node dissection (p = 0.01). CONCLUSION: BCS using the sector resection technique has a low re-excision rate for positive margins. Younger patients and aggressive tumour biology are important predictive risk factors for positive margins.

Community Health Centers Could Provide Better Outsourced Primary Care for Veterans.

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.

Role of radiotherapy in women over the age of 65 after breast conserving surgery for breast cancer: A 5-year retrospective study.

BACKGROUND/OBJECTIVE: This study aimed to analyse the local recurrence (LR) and breast cancer related mortality (BCRM) in older women who underwent breast-conserving surgery (BCS) with and without adjuvant radiotherapy (XRT). METHODS: This retrospective study included a total of 299 women who underwent BCS for early breast carcinoma, between the years of 2007 and 2011. Predictive risk factors, local recurrence (LR) and breast cancer related mortality (BCRM) were assessed with a mean follow-up period of 84 months. RESULTS: Women over the age of 65 in the XRT and No-XRT groups showed similar incidence of LR (5.8% vs 5%, p = 0.838). Women over 65 years old with XRT had a higher rate of BCRM (5.8% vs 0%, p = 0.05). Resection margins >5 mm had a lower rate of BCRM (HR 0.395, p = 0.05). Women under the age of 65, invasive ductal carcinoma, grade-3 tumours, HER-2 positive, triple negative, lympho-vascular invasion, axillary lymph node positivity, high breast density on mammography were associated with increased risk of LR and BCRM. CONCLUSIONS: XRT in women over the age of 65 did not decrease the risk of LR. Adjuvant XRT in older women should be offered to selective patients with high risk patient and tumour factors.

THE NEUMANN PROBLEM ON ELLIPSOIDS.

The Neumann problem on an ellipsoid in Rn asks for a function harmonic inside the ellipsoid whose normal derivative is some specified function on the ellipsoid. We solve this problem when the specified function on the ellipsoid is a normalized polynomial (a polynomial divided by the norm of the normal vector arising from the definition of the ellipsoid). Specifically, we give a necessary and sufficient condition for a solution to exist, and we show that if a solution exists then it is a polynomial whose degree is at most the degree of the polynomial giving the specified function. Furthermore, we give an algorithm for computing this solution. We also solve the corresponding generalized Neumann problem and give an algorithm for computing its solution.

Using a local low rank plus sparse reconstruction to accelerate dynamic hyperpolarized 13C imaging using the bSSFP sequence.

Acceleration of dynamic 2D (T2 Mapping) and 3D hyperpolarized 13C MRI acquisitions using the balanced steady-state free precession sequence was achieved with a specialized reconstruction method, based on the combination of low rank plus sparse and local low rank reconstructions. Methods were validated using both retrospectively and prospectively undersampled in vivo data from normal rats and tumor-bearing mice. Four-fold acceleration of 1-2 mm isotropic 3D dynamic acquisitions with 2-5 s temporal resolution and two-fold acceleration of 0.25-1 mm2 2D dynamic acquisitions was achieved. This enabled visualization of the biodistribution of [2-13C]pyruvate, [1-13C]lactate, [13C, 15N2]urea, and HP001 within heart, kidneys, vasculature, and tumor, as well as calculation of high resolution T2 maps.

Neurobiology of Propofol Addiction and Supportive Evidence: What Is the New Development?

Propofol is a short-acting intravenous anesthetic agent suitable for induction and maintenance of general anesthesia as well as for procedural and intensive care unit sedation. As such it has become an unparalleled anesthetic agent of choice in many institutional and office practices. However, in addition to its idealistic properties as an anesthetic agent, there is accumulating evidence suggesting its potential for abuse. Clinical and experimental evidence has revealed that not only does propofol have the potential to be abused, but also that addiction to propofol shows a high mortality rate. Based on this evidence, different researchers have shown interest in determining the probability of propofol to be an addictive agent by comparing it with other drugs of abuse and depicting a functional similitude that involves the mesocorticolimbic pathway of addiction. In light of this, the Drug Enforcement Agency and the American Society of Anesthesiologists have put forth certain safety recommendations for the use of propofol. Despite this, the abuse potential of propofol has been challenged at different levels and therefore the preeminent focus will be to further validate the linkage from medicinal and occasional use of propofol to its addiction, as well as to explore the cellular and molecular targets involved in establishing this linkage, so as to curb the harm arising out of it. This review incorporates the clinical and biomolecular evidence supporting the abuse potential of propofol and brings forth the promising targets and the foreseeable mechanism causing the propofol addiction phenotypes, which can be called upon for future developments in this field.

3D hyperpolarized C-13 EPI with calibrationless parallel imaging.

With the translation of metabolic MRI with hyperpolarized 13C agents into the clinic, imaging approaches will require large volumetric FOVs to support clinical applications. Parallel imaging techniques will be crucial to increasing volumetric scan coverage while minimizing RF requirements and temporal resolution. Calibrationless parallel imaging approaches are well-suited for this application because they eliminate the need to acquire coil profile maps or auto-calibration data. In this work, we explored the utility of a calibrationless parallel imaging method (SAKE) and corresponding sampling strategies to accelerate and undersample hyperpolarized 13C data using 3D blipped EPI acquisitions and multichannel receive coils, and demonstrated its application in a human study of [1-13C]pyruvate metabolism.

Rethinking Medicaid Coverage and Payment Policy to Promote High Value Care: The Case of Long-Acting Reversible Contraception.

CONTEXT: Long-acting reversible contraception (LARC) is the most effective reversible method to prevent unplanned pregnancies. Variability in state-level policies and the high cost of LARC could create substantial inconsistencies in Medicaid coverage, despite federal guidance aimed at enhancing broad access. This study surveyed state Medicaid payment policies and outreach activities related to LARC to explore the scope of services covered. METHODS: Using publicly available information, we performed a content analysis of state Medicaid family planning and LARC payment policies. Purposeful sampling led to a selection of nine states with diverse geographic locations, political climates, Medicaid expansion status, and the number of women covered by Medicaid. RESULTS: All nine states' Medicaid programs covered some aspects of LARC. However, only a single state's payment structure incorporated all core aspects of high-quality LARC service delivery, including counseling, device, insertion, removal, and follow-up care. Most states did not explicitly address counseling, device removal, or follow-up care. Some states had strategies to enhance access, including policies to increase device reimbursement, stocking and delivery programs to remove cost barriers, and covering devices and insertion after an abortion. CONCLUSIONS: Although Medicaid policy encourages LARC methods, state payment policies frequently fail to address key aspects of care, including counseling, follow-up care, and removal, resulting in highly variable state-level practices. Although some states include payment policy innovations to support LARC access, significant opportunities remain.