Citations

Abstract Objective This study reports development and validation of a deep learning seizure detection algorithm for two‐channel subscalp electroencephalographic (EEG) recordings. Ultra‐long‐term monitoring of people with epilepsy may produce new insights into the timing and pattern of their seizures and may pave the way for novel therapeutic options. Although EEG is the accepted standard for epilepsy monitoring, ultra‐long‐term EEG recordings generate a massive quantity of data and are not reasonably reviewable in full by human readers. Methods The convolutional neural network‐bidirectional long short‐term memory (CNN‐BiLSTM) hybrid algorithm uses nine layers, operating on channel spectrograms 5 min in length with 50% overlap. Retrospective subscalp EEG data from 16 patients recorded at three centers were available for algorithm development and testing. EEG was recorded for a median of 63 days (range = 9–508), and a median of 17 seizures (range = 0–96) were recorded. Training data were augmented with scalp EEG seizures, and performance was benchmarked against a conventional spectral power classifier algorithm. We also evaluated an intrapatient training–testing approach where the algorithm was trained on the first 45% of data. Results The CNN‐BiLSTM trained on scalp EEG and subscalp EEG achieved an area under the receiver operating characteristic curve (AUROC) of .98 and an area under the precision–recall curve (AUPRC) of .50, which correspond to 94% sensitivity with 1.11 false detections per day. The same model trained on iEEG achieved only AUROC = .94 and AUPRC = .36. The conventional spectral band power detector achieved AUROC = .93 and AUPRC = .38. The CNN‐BiLSTM detector trained on the earliest half of the subscalp EEG data achieved AUROC = .93 and AUPRC = .37, corresponding to 87% sensitivity and 5.9 false detections per day. Significance High sensitivity and specificity are possible in automated seizure detection in two‐channel subscalp EEG data using a CNN‐BiLSTM framework. Performance of the detector is superior using subcutaneous EEG data for training rather than intracranial EEG, but addition of scalp EEG seizures for training was helpful.

Objectives The purpose of the current study was to evaluate differences in total sleep time and heart rate variability (HRV) in active-duty firefighters between on-shift and off-shift days. Methods 59 structural firefighters (age: 37.3±7.3 years; height: 1.80±0.08 m; weight: 88.9±14.1 kg and body mass index (BMI): 27.5±4.1 kg/m2) participated in this longitudinal observation study. Each morning for 15 weeks, firefighters were asked to sync a smart ring with a smartphone application to download night-time data, which were then extracted to a cloud-based software application for later analysis. The software also computed a readiness score each morning. All day types were coded as on-shift or off-shift. Results The average nightly sleep time for all firefighters was 6.95±1.24 hours. When off-shift, firefighters recorded more sleep compared with on-shift nights (off-shift: 6.97±0.50 hours vs on-shift: 6.68±0.52 hours; p<0.0001). HRV (p<0.0001) and readiness scores (p=0.02) were lower off-shift compared with on-shift. For the lagged correlation analysis, total sleep time was moderately positively correlated with the following day’s readiness score. Conclusions Firefighters recorded more total sleep time when off-shift compared with on-shift; however, HRV and readiness scores were higher on-shift. The lag-time correlations indicate an association between sleep time and HRV or readiness scores, with approximately half of the variability in readiness being attributable to changes in total sleep time, which highlights the complexity of the readiness and HRV signals/systems.

Objectives: The medial ulnar collateral ligament (MUCL) is the primary stabilizer of valgus forces across the elbow. Injury to the MUCL has a large impact on the throwing athlete, particularly in baseball. The incidence of MUCL injury in baseball pitchers is on the rise. Surgical treatment and rehabilitation is evolving to improve outcomes and improve return to sport time frames. The purpose of this study was to highlight the trends in MUCL repair and reconstruction in professional baseball pitchers, describe relevant outcomes such as return to any level of play (RTP) for surgical repair and reconstruction, and distinguish what factors might impact these outcomes. The authors hypothesize that primary and revision MUCL surgery is increasing with revision surgery requiring the greatest time to RTP. Methods: The Major League Baseball (MLB) Health and Injury Tracking System (MLB HITS) database was used to procure data during the targeted study period (2010 – 2023). All professional pitchers who underwent MUCL surgery within the study period were included. Variables analyzed included age, career length, and level of play. Surgical variables included date and type of procedure, RTP status, time required to RTP, return to same level of play (RTSL), career length before and after surgery, number of revision surgeries, and time between surgeries. Successful RTP was designated if a pitcher had returned in at least one professional game after index surgery. Analyses of trends over time were performed. The year 2020 was considered an outlier and omitted from the analysis of trends due to the coronavirus pandemic which limited games played. Results: A total of 2,287 pitchers underwent MUCL surgery during the study period (Table 1). The annual number of MUCL surgeries on all pitchers increased year over year (R 2 = 0.821, p < 0.001), as did the annual number of reconstructions with internal brace (IB) augmentation (R 2 = 0.896, p < 0.001) (Figure 1). The RTP rate (93%) for MLB pitchers was significantly higher compared to the RTSL rate (71%, P < 0.001). This difference was not observed in Minor League Baseball (MiLB) (RTP 76% vs. RTSL 74%, P = 0.142) (Figure 2). The percentage of players who RTP after revision surgery was significantly lower compared to primary surgery (71%vs. 80% respectively, P = 0.020). Mean time to RTP is significantly shorter (470 ± 135 days) compared to the mean time to RTSL (499 ± 153 days, P < 0.001) (Figure 3). The annual number of revision MUCL surgeries on all pitchers increased year over year as well (R 2 = 0.322, p = 0.043). Conclusions: MUCL surgery continues to increase, also leading to increasing numbers of revisions in professional pitchers. Overall, 80% of pitchers were able to RTP at a mean of 470 days (15.5 months), while only 71% were able to RTSL at a mean of 499 days (16.5 months), but this varied based on level of play. Surgical techniques continue to evolve as MUCL repairs and reconstructions with IB augmentation have increased significantly in recent years. This study will help guide athlete expectations and surgeon decision-making.

ABSTRACTBackgroundPrimary progressive apraxia of speech is a neurodegenerative disorder characterized by early, isolated speech impairment due to impairment of motor speech planning and programming. Patients with PPAOS have varying disease durations from the estimated onset of the first symptom to death. Clinicopathological and neuroimaging features related to disease duration are unknown for PPAOS. We determine whether clinical, neuroimaging, or pathological features are associated with disease duration in primary progressive apraxia of speech (PPAOS).MethodsWe analyzed data from 41 PPAOS participants who were enrolled and longitudinally followed to death in NIH‐funded studies over 15 years. Demographic, clinical, and genetic features were abstracted. Brain volumes of cortical, subcortical, and brainstem regions were calculated. Regional tau lesion count (burden) was assessed histologically. Spearman rank correlations were performed between disease duration and variables of interest, followed by multiple regression analyses.ResultsDisease duration did not correlate with any baseline demographic, clinical, or pathologic features. Shorter disease duration correlated with a faster rate of behavioral change and of apraxia of speech severity over time, smaller baseline volumes of the superior frontal lobe and supplementary motor cortex, and higher tau burden in the locus ceruleus (ρ = −0.5, p = 0.03). Multiple regression analysis identified rate of behavioral change and volume loss in the superior frontal lobe as key clinical and neuroimaging variables, respectively.ConclusionIn patients with PPAOS, we found shorter disease duration to be related to behavioral dyscontrol and involvement of the frontal lobe, as well as a higher burden of 4‐repeat tau lesions in the locus ceruleus.

Abstract Background The past two decades have witnessed tremendous growth in the appreciation and treatment of sacroiliac joint (SIJ) complex pain, including anatomical dissections that shed light on innervation, an appreciation for the contribution of extra-articular components to SIJ complex pain, the advent of radiofrequency ablation (RFA) and a host of minimally invasive surgical techniques. Yet, there is no standardization on diagnosis and treatment paradigms. Methods In February 2023, the Boards of Directors for the American Academy of Pain Medicine (AAPM) and American Society of Regional Anesthesia & Pain Medicine (ASRA-PM) approved the development of multispecialty guidelines on SIJ complex pain. Thirty partner organizations with clinical and scientific interests in SIJ complex pain were identified, and formal letters of request-for-participation were sent to each, along with a request for nominees to serve on the committee. Twenty five organizations agreed to participate in addition to the Departments of Defense and Veterans Affairs. A steering committee developed 21 questions, which spanned criteria for diagnosis, non-interventional and interventional treatments including surgery, technical parameters on how to optimize results, and what constitutes positive outcomes. Questions were methodically assigned to specialized modules comprising 4-5 members with complementary expertise, who collaborated with the Subcommittee Lead and one of three Committee Chairs to develop preliminary drafts. Following thorough revisions, these drafts were subsequently submitted to the full committee for comprehensive review. A modified Delphi method was used in which the answers to questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was achieved. During a committee meeting before commencement, it was agreed that recommendations would be noted when there was &gt;50% agreement among committee members, but that a formal recommendation would require ≥75% consensus. Results Twenty-one organizations formally endorsed the guidelines. The American Society of Anesthesiologists, and American Academy of Physical Medicine & Rehabilitation, and the North American Spine Society affirmed the benefit of the guidelines but did not officially endorse them. The American Academy of Neurology declined to affirm the benefit of the guidelines citing “lack of relevance to their membership.” Per policies, while the Departments of Defense and Veterans Affairs did not formally review the guidelines for endorsement, their representatives approved them. In addition to being endorsed or the benefit affirmed by all voting organizations, complete consensus from committee members was obtained on all 21 questions. On 2 recommendations, there were dissensions from 3 societies who thought that selecting patients for sacral lateral branch RFA and minimally invasive fusion should be based on ≥75% relief from 2 blocks instead of at least 50% relief from a single block before RFA, and greater than 50% pain relief with documented functional improvement after a single block before fusion. One additional society (Latin American Society of Regional Anesthesia) abstained on the statement that the evidence is stronger for extra-articular than intra-articular injections. The committee found that a battery of physical exam tests has reasonable sensitivity, but lower specificity, for identifying intra-articular but not extra-articular pathology, with negative tests having greater predictive value than positive ones. Intra-articular injections have diagnostic validity for SIJ intra-articular, but not extra-articular pain. There is unclear or negative evidence for imaging. The prevalence rates of intra-articular and extra-articular pathology are comparable, with both intra- and extra-articular steroid injections providing at least 4 weeks of relief in well-selected patients. However, the evidence is slightly stronger for extra-articular corticosteroid injections to provide short-term relief. The evidence base for non-interventional therapies is indirect, extrapolated mostly from low back pain studies. There is weak evidence supporting dextrose-based prolotherapy and platelet-rich plasma to provide at least 3 months of pain relief. There is strong evidence for sacral lateral branch RFA to provide relief for at least 6 months in individuals with extra-articular pathology, with face validity and indirect evidence from randomized trials supporting sacral lateral branch blocks as a prognostic tool. There is stronger evidence for larger lesions or more aggressive lesioning strategies than for less stringent techniques. There is weak evidence to support non-steroidal anti-inflammatory drugs to prevent neuritis after RFA, and in most cases anticoagulation does not require cessation in the periprocedural perioid. With an aggressive lesioning strategy, sensory stimulation provides minimal therapeutic benefit, with weak, extrapolated evidence that motor stimulation can provide safety benefit. The cutoff to designate diagnostic or prognostic blocks as positive is most commonly set at 50%, with higher values not shown to improve outcomes for more definitive procedures; for therapeutic treatment outcomes, the evidence supports a lower threshold of ≥30% pain relief or meaningful benefit on non-pain outcomes (eg, opioid cessation) for designation of a positive response. For carefully selected patients with intra-articular SIJ complex pain based on controlled blocks who have failed conservative therapies, there is weak or very weak evidence that minimally invasive SIJ fusion can provide benefit for at least one year. Conclusions SIJ complex pain remains an underappreciated source of chronic low back pain, affecting between 15% and 30% of patients with axial pain predominantly below L5. Answers to many questions were limited by low-quality evidence, indicating the need for better research. SIJ complex pain is a multifarious condition (ie, pain can be from different portions of both the intra- and extra-articular components of the joint) for which an interdisciplinary, multimodal treatment plan can optimize treatment outcomes.

ABSTRACT Objective Autosomal dominant progranulin ( GRN ) pathogenic variants are a genetic cause of frontotemporal lobar degeneration. Though clinical trials for GRN ‐related therapies are underway, there is an unmet need for biomarkers that can predict symptom onset and track disease progression. We previously showed that asymptomatic GRN variant carriers exhibit thalamocortical hyperconnectivity that increases with age, presumably as they are approaching symptom onset. Whether hyperconnectivity arises concomitantly with markers of neurodegeneration remains unclear. Methods Utilizing T1 and task‐free functional magnetic resonance imaging from 49 asymptomatic and 26 symptomatic GRN variant carriers, we determined the relationships between functional connectivity, as measured by voxelwise whole‐brain degree, and GRN ‐relevant markers of disease progression, including plasma neurofilament light chain concentrations, cerebrospinal fluid complement C1q and C3b protein levels, obsessive‐compulsive disorder symptom severity, and gray matter volume. Results Neurofilament light chain concentrations were associated with frontotemporoparietal and thalamic hyperconnectivity in asymptomatic GRN variant carriers and extensive regions of atrophy in symptomatic carriers. Complement levels were associated with regions of hyperconnectivity, but not gray matter volume, in symptomatic carriers. Obsessive‐compulsive disorder symptom severity was associated with hypoconnectivity across all GRN carriers. Asymptomatic carriers with thalamic hyperconnectivity tended to have lower gray matter volume in the bilateral insula and left lateral parietal cortex, early regions of atrophy in GRN ‐frontotemporal dementia. Interpretation In asymptomatic carriers, the co‐occurrence of hyperconnectivity, high neurofilament light chain, and low gray matter volume suggests that functional hyperconnectivity may portend the onset of clinical decline. These findings point toward hyperconnectivity as an indicator of approaching symptomatic onset.

Abstract Electronic portal imaging devices (EPIDs) have been in widespread clinical use for almost two decades due to favorable measurement characteristics such as fast image acquisition, high sensitivity and resolution, digital data format, long‐term stability, linear dose response, and large detection area. On‐board EPIDs are widely used as a quality assurance (QA) tool to monitor nearly every aspect of linear accelerator (linac) performance. In both the commercial QA equipment market and in clinical practice, there is a trend toward replacing conventional QA approaches with fully automated, EPID‐based QA tools. Despite widespread use, EPIDs are complex devices, and there has yet to be consensus or formal recommendations published by the AAPM for their use in routine linac QA. Task Group 330 (TG‐330) was, therefore, formed to provide guidelines and recommendations for physicists on the safe and appropriate use of EPIDs for linac QA. In particular, the report: (a) provides a comprehensive review of the characteristics and limitations of EPIDs as time‐resolved measurement devices and dosimeters; (b) summarizes the application of EPIDs for linac QA; (c) provides recommendations on efficient and effective implementations of EPID‐based QA techniques; (d) describes risks associated with the use of EPIDs for linac QA and provides examples of how risk analysis can be used to ensure the safe use of EPIDs for linac QA. Many of the guidelines in this report are drawn from the literature that is included in the references and from the collective experience of the task group members. This report does not provide recommendations on the implementation of EPID‐based patient‐specific IMRT or VMAT QA, which is the topic of AAPM's report from AAPM TG‐307.

OBJECTIVE The purpose of this study was to evaluate whether level selection for a three-column osteotomy (3CO) impacts cervical deformity correction outcomes, including neurological, radiographic, and patient-reported outcomes. METHODS A retrospective review was performed of patients who underwent a cervical or upper thoracic 3CO for cervical deformity correction by the senior author from 2008 to 2024. Collected outcome measures included neurological outcomes, mechanical complication rates, spinopelvic alignment, and patient-reported outcomes. The minimum follow-up was 1 year. RESULTS One hundred fifteen patients were identified who underwent a cervical or upper thoracic 3CO for cervical deformity correction, of whom 77 met inclusion criteria for this study with a minimum follow-up of 1 year. The median age was 66 years, the median BMI was 27, and 43% of patients were male. Sixteen patients underwent a 3CO at the C7–T1 levels and 61 patients at T2–6 levels. Patients who underwent C7–T1 3CO were more likely to experience a new postoperative neurological deficit compared with those who underwent T2–6 3CO (56% vs 18%, p = 0.004), had less correction in their T1 slope (6° vs 18°, p = 0.027), had less correction in C2–T4 sagittal vertical axis (2.8 cm vs 4.9 cm, p = 0.043), and had a worse Neck Disability Index (NDI) score at 1 year compared with baseline (an increase of 7 vs a decrease of 12, p = 0.033). CONCLUSIONS Cervical deformity patients who underwent a 3CO at C7–T1 had a higher rate of postoperative neurological deficits, less radiographic correction, and worse NDI scores at 1 year compared with patients who underwent a 3CO from T2 to T6. Although 3CO level selection is multifactorial and patient specific, surgeons should consider a 3CO level caudal to T1 when feasible.

This study used semi-structured interviews with 11 key opinion leaders to explore why dermatologist involvement in innovation remains limited despite growing investment in the field. It found that barriers such as limited early exposure to industry, time constraints and goal misalignment hinder engagement, but also highlighted solutions like integrating industry exposure into training and fostering new funding models. These findings suggest actionable strategies to bridge gaps between clinicians and industry and promote dermatological innovation.