Citations

Abstract Introduction Skull base neuroanatomy is classically taught using surgical atlases. Although these texts are critical and rich resources for learning three-dimensional (3D) relationships between key structures, we believe they could be optimized and complemented with step-by-step anatomical dissections to fully meet the learning needs of trainees. Methods Six sides of three formalin-fixed latex-injected specimens were dissected under microscopic magnification. A far lateral craniotomy was performed by each of three neurosurgery resident/fellow at varying stages of training. The study objective was the completion and photodocumentation of the craniotomy to accompany a stepwise description of the exposure to provide a comprehensive, intelligible, and anatomically oriented resource for trainees at any level. Illustrative case examples were prepared to supplement approach dissections. Results The far lateral approach provides a wide and versatile corridor for posterior fossa operation, with access spanning the entire cerebellopontine angle (CPA), foramen magnum, and upper cervical region. Key Steps Include The study includes the following steps: positioning and skin incision, myocutaneous flap, placement of burr holes and sigmoid trough, fashioning of the craniotomy bone flap, bilateral C1 laminectomy, occipital condyle/jugular tubercle drilling, and dural opening. Conclusion Although more cumbersome than the retrosigmoid approach, a far lateral craniotomy offers unparalleled access to lesions centered lower or more medially in the CPA, as well as those with significant extension into the clival or foramen magnum regions. Dissection-based neuroanatomic guides to operative approaches provide a unique and rich resource for trainees to comprehend, prepare for, practice, and perform complex cranial operations, such as the far lateral craniotomy.

Abstract Introduction Ki-67 is often used as a proliferation index to evaluate how aggressive a tumor is and its likelihood of recurrence. Vestibular schwannomas (VS) are a unique benign pathology that lends itself well to evaluation with Ki-67 as a potential marker for disease recurrence or progression following surgical resection. Methods All English language studies of VSs and Ki-67 indices were screened. Studies were considered eligible for inclusion if they reported series of VSs undergoing primary resection without prior irradiation, with outcomes including both recurrence/progression and Ki-67 for individual patients. For published studies reporting pooled Ki-67 index data without detailed by-patient values, we contacted the authors to request data sharing for the current meta-analysis. Studies reporting a relationship between Ki-67 index and clinical outcomes in VS for which detailed patients' outcomes or Ki-67 indices could not be obtained were incorporated into the descriptive analysis, but excluded from the formal (i.e., quantitative) meta-analysis. Results A systematic review identified 104 candidate citations of which 12 met inclusion criteria. Six of these studies had accessible patient-specific data. Individual patient data were collected from these studies for calculation of discrete study effect sizes, pooling via random-effects modeling with restricted maximum likelihood, and meta-analysis. The standardized mean difference in Ki-67 indices between those with and without recurrence was calculated as 0.79% (95% confidence interval [CI]: 0.28–1.30; p = 0.0026). Conclusion Ki-67 index may be higher in VSs that demonstrate recurrence/progression following surgical resection. This may represent a promising means of evaluating tumor recurrence and potential need for early adjuvant therapy for VSs.

Ibrutinib-based therapies are costly and require continuous administration. We hypothesized combining BTK inhibition with anti-CD20 monoclonal antibodies would yield deep remissions allowing discontinuation. We enrolled 32 therapy-naïve CLL patients to receive ibrutinib plus obinutuzumab, followed by single-agent ibrutinib. Patients could discontinue ibrutinib after 36 months with sustained complete response (CR). We evaluated treatment safety, efficacy, and outcomes after ibrutinib discontinuation. The overall response rate was 100%, 28% achieved a CR, and 12.5% achieved bone marrow undetectable minimal residual disease. At a three-year median follow-up, 91% remain in remission with 100% overall survival. Five patients in sustained CR stopped ibrutinib and have not progressed. Eight non-CR patients discontinued for other reasons, with only two progressing. The treatment was safe, with a lower IRR rate. All patients responded to treatment with longer time-to-progression after discontinuation of ibrutinib. Our data support the evaluation of ibrutinib discontinuation strategies in more extensive clinical trials (https://Clinicaltrials.gov Identifier https://clinicaltrials.gov/ct2/show/NCT02315768).

Purpose To determine if bedside rounds, compared with other forms of hospital ward rounds, improve learning outcomes in medical education. Method For this systematic review, the authors searched Ovid MEDLINE, Embase, and Scopus from inception through February 20, 2020. Experimental studies were included if they (1) compared bedside rounds to any other form of rounds in a hospital-based setting, and (2) reported a quantitative comparison of a learning outcome (e.g., learner reaction, knowledge, skills, behavior, health care delivery) among physicians-in-training (medical students, residents, fellows). Extraction elements were summarized using descriptive statistics and a narrative synthesis of design, implementation, and outcomes. Results Twenty studies met inclusion criteria, including 7 randomized trials. All studies involved resident physicians, and 11 also involved medical students. The design and implementation of bedside rounds varied widely, with most studies (n = 13) involving cointerventions (e.g., staff education, real-time order entry). Of the 15 studies that reported learner satisfaction, 7 favored bedside rounds, 4 favored the control, and 4 were equivocal. Of the 4 studies reporting an outcome of learners’ knowledge and skills, 2 favored bedside rounds and 2 were equivocal. Of the 8 studies that reported on learner behavior (e.g., bedside communication with patients), 5 favored bedside rounds, 1 favored the control, and 2 were equivocal. Finally, of the 14 studies that reported a health care delivery outcome (e.g., teamwork, rounding time), 8 favored bedside rounds and 6 were equivocal. Due to the high risk of bias and unexplained heterogeneity across studies, the overall strength of evidence was low. Conclusions In hospital-based settings, learners’ satisfaction with bedside rounds is mixed. However, bedside rounds appear to have a positive effect on learner behavior and health care delivery. Given their potential value, additional research is needed to identify barriers to and facilitators of educationally successful bedside rounds.

AbstractObjectiveDescribe the presentation and management strategy for patients with symptomatic foramen of Huschke (FH).PatientsAdults with persistent FH confirmed on imaging.InterventionsDiagnosis and management of symptomatic persistent FH.Main outcome measureResolution of otologic symptoms.ResultsA total of four patients with symptomatic, radiographically‐confirmed persistent FH were included. The majority of patients endorsed otalgia (n = 4) and otorrhea (n = 3), and only one patient was noted to have a conductive hearing loss. All patients were noted to have dynamic movement of an external auditory canal mass with mandible manipulation on examination, and all patients had an identifiable fistula on imaging. Patients underwent surgical intervention, including both preauricular (n = 2) and transcanal (n = 2) approaches, and all endorsed symptomatic resolution after convalescence.ConclusionsPersistent FH remains an uncommon and potentially underrecognized cause of otologic symptoms. Diagnosis requires a high index of suspicion, and one must rely on both key examination findings and imaging to confirm this diagnosis. In appropriately selected patients, surgical intervention can provide durable symptomatic resolution.Level of evidenceIV

AbstractBackgroundRecent advances in the development of novel Alzheimer’s disease (AD) measures of amyloid, tau, and neurodegeneration in cerebrospinal fluid (CSF) and blood have enabled a better understanding of the links between amyloid‐beta (Aβ), tau species and neurodegeneration in the brain, CSF, and blood. The discoveries of novel tau species in CSF and blood, including specific phospho‐tau (p‐tau) and truncated species containing the microtubule binding region of tau (MTBR‐tau) which aggregates in tau tangles, have greatly expanded our understanding of tau biology and tau target development. The longitudinal Aβ, tau, and neurofilament light chain (NfL) changes previously measured in CSF are now being measured accurately in blood, enabling interpretation and understanding of AD progression in much larger and more robust populations.MethodWe analyzed longitudinal CSF and/or blood plasma mass spectrometry measures of Aβ42/Aβ40, multiple p‐tau species (including p‐tau217, 231, 181, 205, etc.), total tau, MTBR‐tau (e.g., MTBR‐tau243, MTBR‐tau299, and MTBR‐tau354), and NfL in sporadic AD and dominantly inherited AD cohorts. Mass spectrometry results were compared to amyloid and tau aggregation measures by Positron Emission Tomography (PET) scans and clinical and cognitive measures in local and international clinical cohorts including ADNI, AIBL, BioFINDER, Mayo Clinic, the Knight ADRC, and the DIAN.ResultThe longitudinal results indicate that a pathophysiological cascade of events begin with altered CSF and blood plasma Aβ42/Aβ40 ratio, followed by increases in amyloid plaques as measured by amyloid PET, associated with increased phosphorylation of specific CSF tau species (e.g., p‐tau217, p‐tau181, etc.), before increases in p‐tau205, NfL, total tau concentrations, hypometabolism, and atrophy. Finally, some species of MTBR‐tau increase before or with tau aggregation by tau PET and onset of clinical symptoms and correlate with longitudinal tau aggregation and clinical progression.ConclusionThese findings indicate that CSF and blood plasma Aβ, p‐tau, MTBR‐tau and NfL measures are highly precise biomarkers of brain amyloidosis, tauopathy, and neurodegeneration and can accurately identify stages of preclinical and clinical AD.