Brigham, Tara

Objective: To estimate the relative risk of meningitis after repair of spontaneous lateral skull base cerebrospinal fluid (CSF) leaks through meta-analysis of published studies. Databases Reviewed: PubMed, Medline, Embase, Cochrane, SCI-EXPANDED, ESCI, Epistemonikos, and WHO Global Index Medicus were queried for terms including and related to meningitis, CSF leak, surgery, and spontaneous from inception to April 02, 2024. Methods: Prospective and retrospective studies in any language reporting either preoperative or postoperative rates of meningitis in adults with spontaneous lateral skull base CSF leaks were included. Two reviewers independently screened 2,564 studies and extracted data and evaluated risk of bias in 57 studies that met inclusion criteria. A random effects generalized linear mixed model was used to pool and compare logit transformed risk of meningitis before and after repair. Results: Of 1,310 patients who met inclusion criteria, 1,239 underwent CSF leak repair. Fifty-two studies reported rates of preoperative meningitis, and 27 studies reported rates of postoperative meningitis. Twenty-two studies with a total of 511 patients reported both rates. The average follow-up period of 17 studies reporting duration of follow-up was 23.1 months. The preoperative pooled risk of meningitis was 0.16 (95% CI: 0.13–0.25, I 2 = 40.57%). The postoperative pooled risk was considerably lower at 0.01 (95% CI: 0.01–0.14, I 2 = 4.16%). With substantial heterogeneity (I 2 = 62.94%), we observed a relative risk of meningitis after repair of 0.02 (95% CI: 0.00–0.79, p = 0.04). Conclusion: Surgical repair of spontaneous lateral skull base CSF leaks may significantly reduce the risk of adult meningitis.

Objective: Assess the impact of adult cochlear implantation on the disability and quality of life (QOL) of communication partners (CP) of cochlear implant (CI) recipients. Databases reviewed: PubMed, MEDLINE, Embase, Cochrane CENTRAL, Science Citation Index Expanded, and Emerging Sources Citation Index were searched. Methods: This study was reported following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Articles included reported on disability or QOL measures of CP of adult CI recipients. Study selection included retrospective, prospective, and randomized controlled studies in English language. Three reviewers independently screened studies for inclusion, extracted data, and evaluated risk of bias. Outcomes included both qualitative and quantitative pre-CI and post-CI measures of CP disability or QOL. Results: Of 1615 screened articles, 9 studies utilizing quantitative and qualitative measures with 504 CP met inclusion criteria. Four of 6 studies assessing only post-CI CP QOL, demonstrated self-reported improvement, while one demonstrated worse CP QOL compared with the general population and one identified CP and CI recipient qualities that correlated with CP QOL scores. Two studies assessing pre-CI to post-CI CP QOL also reported improvements. One study assessing only pre-CI CP QOL suggested that CPs had worse QOL than normal hearing controls. Duration of CI recipient hearing loss did not impact CP QOL in any study. Conclusions: Though homogenous data on the QOL of CPs of CI recipients and the relationship between CI recipient and CP factors is limited, studies suggest that CPs of CI recipients may have worse QOL than the general population but, cochlear implantation may improve CP QOL.

AbstractBackgroundThe term rapidly progressive dementia (RPD) may be applied to patients with precipitous declines in cognitive function resulting in dementia within one year or complete incapacitation within two‐years of symptom onset. Although most patients present with subacute, progressive declines, selected patients develop complete incapacitation within seven days of symptom onset. The differential diagnosis and clinical characteristics of patients with abrupt‐onset dementia are not known.Method187 patients with RPD were prospectively enrolled from February 2016 to September 2023 in a study of RPD at Mayo Clinic (Jacksonville, Florida) and Washington University (Saint Louis, Missouri). Patients with ≤7 days from first symptom to onset of RPD were labelled as abrupt onset. Patient characteristics, results of investigations, and causes of abrupt‐onset dementia were further characterized. We further explored the causes of abrupt‐onset dementia in the extant literature to refine the differential diagnosis and approach to evaluation and management of these patients.ResultTwo patients in our study of RPD had abrupt‐onset RPD (2/187, 1.1%), attributed to autoimmune and vascular. An additional 63 cases were identified through comprehensive meta‐narrative review of the literature (40 publications). Causes of abrupt‐onset dementia include vascular, infectious, inflammatory, and toxic. Compromise of structures within the Papez circuit was a common unifying feature common across patients with varying etiologies, informing the localization of abrupt‐onset dementia. 20% cases had potentially treatment‐responsive causes of abrupt‐onset dementia.ConclusionCases of abrupt‐onset dementia are rare overall and associated with a limited differential diagnosis. Evaluation of patients with abrupt‐onset dementia should prioritize testing for vascular, autoimmune, infectious, and toxic causes. Early‐recognition of patients with potentially treatment‐responsive causes of dementia may promote earlier intervention leading to better outcomes in selected patients.

A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.