Citations

Abstract Introduction The middle fossa (MF) approaches encompass a group of versatile surgical accesses to pathologies in the MF, internal auditory canal (IAC), and superomedial aspect of the posterior fossa. Although many descriptions of the MF approaches have been published, a practical surgical guide that allows an easy understanding for Skull Base trainees is needed. Methods Three formalin-fixed, colored-injected specimens were dissected under microscopic magnification (six sides). A MF craniotomy followed by IAC drilling was performed on three sides, and anterior petrosectomy (AP) was performed in the remaining three sides. The anatomical dissection was documented in stepwise three-dimensional photographic images. Following dissection, representative case applications were reviewed. Results The MF approach provides direct access to the MF structures and IAC. The AP provides excellent access to the superomedial aspect of the posterior fossa. Key common steps include: positioning and skin incision; scalp and muscle flaps; burr holes; craniotomy flap elevation; dural dissection along the petrous ridge; division of the middle meningeal artery; and exposure of the greater superficial petrosal nerve, tegmen tympani, and V3. Then, to approach the IAC: superior IAC drilling, and longitudinal dura opening. The area drilled in the AP approach forms a pentagon limited by the petrous internal carotid artery, cochlea, IAC, petrous ridge, and lateral border of V3. Conclusion The MF approaches are challenging. Operatively oriented skull base dissections provide a crucial foundation for learning these techniques. We describe comprehensive step-by-step approaches intended to develop familiarity in the cadaver laboratory and facilitate understanding of their potential for skull base disorders. Basic surgical principles are described to help in the operating room as well as illustrative cases.

Abstract PurposeTo clarify the need for post-operative radiation treatment in skull base chondrosarcomas (SBCs).MethodsA retrospective analysis of patients with grade I or II SBC. Patients were divided according to post-surgical treatment strategies: (A) planned upfront radiotherapy and (B) watchful waiting. Tumor control and survival were compared between the treatment groups. The median follow-up after resection was 105 months (range, 9-376).ResultsThirty-two patients (Grade 1, n = 16; Grade 2, n = 16) were included. The most frequent location was petroclival (21, 64%). A gross total resection (GTR) was achieved in 11 patients (34%). Fourteen (44%) underwent upfront radiotherapy (group A) whereas 18 (56%) were followed with serial MRI alone (group B). The tumor control rate for the entire group was 77% and 69% at 10- and 15-year, respectively. Upfront radiotherapy (P = 0.25), extent of resection (P = 0.11) or tumor grade (P = 0.83) did not affect tumor control. The majority of Group B patients with recurrent tumors (5/7) obtained tumor control with repeat resection (n = 2), salvage radiotherapy (n = 2), or a combination of both (n = 1). The 10-year disease-specific survival was 95% with no difference between the group A and B (P = 0.50). ConclusionFor patients with grade I/II SBC, a reasonable strategy is deferral of radiotherapy after maximum safe resection until tumor progression or recurrence. At that time, most patients can be successfully managed with salvage radiotherapy or surgery. Late recurrences may occur, and life-long follow-up is advisable.

Objective: To compare language and audiological outcomes among infants (<9 and <12 mo) and older children receiving cochlear implantation (CI). Study design: Retrospective chart review. Setting: Tertiary academic referral center. Patients: Pediatric patients receiving CI between October 1995 and October 2019. Intervention: Cochlear implantation Main Outcome Measures: Most recent language and audiological assessment scores were evaluated by age group. Results: A total of 118 children were studied, including 19 who were implanted <9 months of age, 19 implanted 9 to <12 months of age, and 80 implanted 12 to <36 months of age. The mean duration of follow-up was 7.4 ± 5.0 years. Most recent REEL-3 receptive (88 ± 12 vs. 73 ± 15; p = 0.020) and expressive (95 ± 13 vs. 79 ± 12; p = 0.013) communication scores were significantly higher in the <9 months group compared to the 9 to <12 months group. PLS and OWLS auditory comprehension and oral expression scores were significantly higher in the <12 months group compared to the 12 to <36 months group. The difference in NU-CHIPS scores between <12 and 12 to <36 months was statistically significant (89% ± 6 vs. 83% ± 12; p = 0.009). LNT scores differed significantly between <9 and 9 to <12 months (94% ± 4 vs. 86% ± 10; p = 0.028). Conclusions: The recent FDA expansion of pediatric CI eligibility criteria to include infants as young as 9 months of age should not serve as a strict clinical cutoff. Rather, CI can be pursued in appropriately selected younger infants to optimize language and audiological outcomes.

Objective: To compare the prevalence of surgical, anesthetic, and device-related complications among infants and older children receiving cochlear implantation (CI). Study Design: Retrospective chart review. Setting: Tertiary academic referral center. Patients: Pediatric patients who underwent CI from November 1990 to January 2020. Intervention: CI. Main Outcome Measures: Surgical, anesthetic, and device-related complication rates were compared by age group (<12 versus 12–23 versus 24+ months with subset analysis of <9 versus 9–11 months). Results: A total of 406 primary pediatric CI surgeries encompassing 482 ears were analyzed, including 45 ears in 23 patients implanted less than 9 months and 89 ears in 49 patients less than 12 months. No anesthetic complications occurred. Postoperative surgical and device-related complication rates were not significantly different among the less than 12, 12 to 23, and 24+ month groups (16% versus 16% versus 12%; p = 0.23) or between the less than 9 and 9 to 11 month groups (22% versus 9%; p = 0.09). Thirty-day readmission was significantly higher for patients less than 12 months compared with patients 24+ months (6% versus <1%; p = 0.011), but was not significantly higher compared with patients 12 to 23 months (6% versus 3%; p = 0.65). Reoperation rates did not differ significantly among the less than 12, 12 to 23, and 24+ month groups (10% versus 7% versus 6%; p = 0.31). Conclusions: The prevalence of surgical, anesthetic, and device related complications was not significantly different among infants implanted less than 9 or less than 12 months of age when compared with older children. These data provide evidence for the continued expansion of pediatric cochlear implant candidacy criteria to include appropriately selected infants less than 9 months of age.

Abstract Objectives To measure nurse-perceived electronic health records (EHR) usability with a standardized metric of technology usability and evaluate its association with professional burnout. Methods A cross-sectional survey of a random sample of US nurses was conducted in November 2017. EHR usability was measured with the System Usability Scale (SUS; range 0–100) and burnout with the Maslach Burnout Inventory. Results Among the 86 858 nurses who were invited, 8638 (9.9%) completed the survey. The mean nurse-rated EHR SUS score was 57.6 (SD 16.3). A score of 57.6 is in the bottom 24% of scores across previous studies and categorized with a grade of “F.” On multivariable analysis adjusting for age, gender, race, ethnicity, relationship status, children, highest nursing-related degree, mean hours worked per week, years of nursing experience, advanced certification, and practice setting, nurse-rated EHR usability was associated with burnout with each 1 point more favorable SUS score and associated with a 2% lower odds of burnout (OR 0.98; 95% CI, 0.97–0.99; P &lt; .001). Conclusions Nurses rated the usability of their current EHR in the low marginal range of acceptability using a standardized metric of technology usability. EHR usability and the odds of burnout were strongly associated with a dose-response relationship.

Abstract Here we analyze hospitalized andintensive care unit coronavirus disease 2019 (COVID‐19) patient outcomes from the international VIRUS registry ( https://clinicaltrials.gov/ct2/show/NCT04323787 ). We find that COVID‐19 patients administered unfractionated heparin but not enoxaparin have a higher mortality‐rate (390 of 1012 = 39%) compared to patients administered enoxaparin but not unfractionated heparin (270 of 1939 = 14%), presenting a risk ratio of 2.79 (95% confidence interval [CI]: [2.42, 3.16]; p = 4.45e−52). This difference persists even after balancing on a number of covariates including demographics, comorbidities, admission diagnoses, and method of oxygenation, with an increased mortality rate on discharge from the hospital of 37% (268 of 733) for unfractionated heparin versus 22% (154 of 711) for enoxaparin, presenting a risk ratio of 1.69 (95% CI: [1.42, 2.00]; p = 1.5e−8). In these balanced cohorts, a number of complications occurred at an elevated rate for patients administered unfractionated heparin compared to patients administered enoxaparin, including acute kidney injury, acute cardiac injury, septic shock, and anemia. Furthermore, a higher percentage of Black/African American COVID patients (414 of 1294 [32%]) were noted to receive unfractionated heparin compared to White/Caucasian COVID patients (671 of 2644 [25%]), risk ratio 1.26 (95% CI: [1.14, 1.40]; p = 7.5e−5). After balancing upon available clinical covariates, this difference in anticoagulant use remained statistically significant (311 of 1047 [30%] for Black/African American vs. 263 of 1047 [25%] for White/Caucasian, p = .02, risk ratio 1.18; 95% CI: [1.03, 1.36]). While retrospective studies cannot suggest any causality, these findings motivate the need for follow‐up prospective research into the observed racial disparity in anticoagulant use and outcomes for severe COVID‐19 patients.

Abstract Large Phase 3 clinical trials of the two FDA-approved COVID-19 vaccines, mRNA-1273 (Moderna) and BNT162b2 (Pfizer/BioNTech), have demonstrated efficacies of 94.1% (n = 30,420, 95% CI: 89.3-96.8) and 95% (n = 43,448, 95% CI: 90.3-97.6) in preventing symptomatic COVID-19, respectively. Given the ongoing vaccine rollout to healthcare personnel and residents of long-term care facilities, here we provide a preliminary assessment of real-world vaccination efficacy in 62,598 individuals from the Mayo Clinic and associated health system (Arizona, Florida, Minnesota, Wisconsin) between December 1st 2020 and February 8th 2021. Our retrospective analysis contrasts 31,299 individuals receiving at least one dose of either vaccine with 31,299 unvaccinated individuals who are propensity-matched based on demographics, location (zip code), and number of prior SARS-CoV-2 PCR tests. Administration of two COVID-19 vaccine doses was 89.0% effective in preventing SARS-CoV-2 infection (95% CI: 69.1-97.2%) with onset at least 36 days after the first dose. Furthermore, vaccinated patients who were subsequently diagnosed with COVID-19 had significantly lower 14-day hospital admission rates than propensity-matched unvaccinated COVID-19 patients (3.7% vs. 9.2%; Relative Risk: 0.4; p-value: 0.007). Building upon the previous randomized trials of these vaccines, this study demonstrates their real-world effectiveness in reducing the rates of SARS-CoV-2 infection and COVID-19 severity among individuals at highest risk for infection.

Abstract Background 3D printing—also known as additive manufacturing—has a wide range of applications. Reproduction of low-cost, high-fidelity, disease- or patient-specific models presents a key developmental area in simulation and education research for complex cranial surgery. Methods Using cadaveric dissections as source materials, skull base models were created, printed, and tested for educational value in teaching complex cranial approaches. In this pilot study, assessments were made on the value of 3D printed models demonstrating the retrosigmoid and posterior petrosectomy approaches. Models were assessed and tested in a small cohort of neurosurgery resident subjects (n = 3) using a series of 10 radiographic and 2 printed case examples, with efficacy determined via agreement survey and approach selection accuracy. Results All subjects indicated agreement or strong agreement for all study endpoints that 3D printed models provided significant improvements in understanding of neuroanatomic relationships and principles of approach selection, as compared to 2D dissections or patient cross-sectional imaging alone. Models were not superior to in-person hands-on teaching. Mean approach selection accuracy was 90% (±13%) for 10 imaging-based cases, or 92% (±7%) overall. Trainees strongly agreed that approach decision-making was enhanced by adjunctive use of 3D models for both radiographic and printed cases. Conclusion 3D printed models incorporating skull base approaches and/or pathologies provide a compelling addition to the complex cranial education armamentarium. Based on our preliminary analysis, 3D printed models offer substantial potential for pedagogical value as dissection guides, adjuncts to preoperative study and case preparation, or tools for approach selection training and evaluation.

AbstractAimsLong‐term lithium therapy (LTLT) has been associated with kidney insufficiency in bipolar disorder (BD). We aimed to investigate the risk factors of chronic kidney disease (CKD) development and progression among BD patients receiving LTLT.MethodsWe included adult patients with BD on LTLT (≥1 year) who were enrolled in the Mayo Clinic Bipolar Biobank, Rochester, Minnesota. We reviewed electronic medical records to extract information related to lithium therapy and kidney‐related data to assess changes in the estimated glomerular filtration rate (eGFR). CKD severity was assessed based on eGFR.ResultsAmong 154 patients who received LTLT, 41 patients (27%) developed CKD, of whom 20 (49%) patients continued lithium (continuers) and 19 (46%) discontinued it (discontinuers). The median time to stage 3 CKD development was 21.7 years from the start of Li treatment. Type‐2 diabetes mellitus and benzodiazepine use were independent predictors for CKD development in the survival analysis, after controlling for age. The subsequent CKD progression rate did not differ between continuers and discontinuers (mean GFR 48.6 vs. 44.1, p = 0.13) at the end of follow‐up duration (mean duration: 3.5 ± 4.4 years for continuers and 4.9 ± 5.3 years for discontinuers).ConclusionCKD was observed in one fourth of patients with BD receiving LTLT. There was no significant difference in the progression of CKD among Li continuers versus discontinuers, at the mean follow‐up duration of 4.2 years, after the CKD diagnosis. Progression of CKD could be influenced by existing comorbidities and may not necessarily be due to lithium alone.