Citations

Abstract Rationale Among tobacco-exposed persons with preserved spirometry (TEPSs), we previously demonstrated that different lung volume indices—specifically, elevated total lung capacity (TLC) versus elevated ratio of functional residual capacity to TLC (FRC/TLC)—identify different lung disease characteristics in the COPDGene cohort. Objective We sought to determine differential disease characteristics and trajectories associated with lung volume indices among TEPSs in the SPIROMICS cohort. Methods We categorized TEPSs (n = 814) by tertiles (low, intermediate, and high) of TLC or residual volume–to-TLC ratio (RV/TLC) derived from baseline computed tomography images and then examined clinical and spirometric disease trajectories in mutually exclusive categories of participants with high TLC without high RV/TLC ([TLC]high) versus high RV/TLC without high TLC ([RV/TLC]high). We examined differences in computed tomography–measured emphysema (Hounsfield units [HU] ⩽−950; parametric response mapping [PRM] of emphysema), air trapping (HU⩽−856; PRM of functional small airway disease; a disease probability measure for non-emphysematous gas trapping), airway geometry (the mean square root of wall area of a hypothetical airway with 10 mm internal perimeter), respiratory symptoms (on the modified Medical Research Council Dyspnea Scale; COPD Assessment Test [CAT]; St. George’s Respiratory Questionnaire [SGRQ]; and Short Form-12 [SF12]), and outcomes (annualized exacerbation rate) between the two categories at baseline and over follow-up time up to 8.5 years, using regression modeling adjusted for age, sex, height, weight, and smoking status (current vs. former smoker) and burden (pack-years). Results In TEPSs, the pattern of spirometric disease progression differed between participants with [TLC]high and those with [RV/TLC]high: There was increased forced vital capacity with stable forced expiratory volume in 1 second in participants with [TLC]high, versus unchanged forced vital capacity but nominally decreased forced expiratory volume in 1 second in those with [RV/TLC]high. Compared with participants with [TLC]high, TEPSs with [RV/TLC]high had less emphysema (by HU ⩽−950) but more airway disease (by HU ⩽−856; PRM of functional small airway disease; disease probability measure for gas trapping, and mean square root of wall area of a hypothetical airway with 10 mm internal perimeter), more respiratory symptoms (on the modified Medical Research Council Dyspnea Scale, CAT, SGRQ, and SF12), and more severe exacerbations at baseline. Over an average follow-up of 4.1 ± 2.4 years (range = 0.5–8.5 yr), TEPSs with [RV/TLC]high also had a higher likelihood of developing more severe spirometric disease (preserved ratio impaired spirometry or Global Initiative for Chronic Obstructive Lung Disease Classification 2) and worsening of their respiratory symptoms (on the CAT and SGRQ). Although the incidence rates of respiratory exacerbations, hospitalizations, and mortality were not significantly different between the two categories over the follow-up period, TEPSs with [RV/TLC]high were more likely to have been prescribed a respiratory inhaler at their last follow-up visit. Conclusions In these TEPSs from the SPIROMICS cohort, lung volume stratification by TLC versus RV/TLC identifies two pre-COPD phenotypes with distinct respiratory symptoms, radiographic features, and clinical trajectories. The characteristics of these pre-COPD phenotypes match those previously described in the COPDGene cohort using TLC versus FRC/TLC stratification.

Abstract Critical findings in radiology reports are life threatening conditions that need to be communicated promptly to physicians (“critical findings”) for timely man-agement of patients. Flagging radiology reports of such incidents could facilitate opportune communication of critical findings. With advancements in natural language processing (NLP), large language models (LLMs) can be trained with task-specific instructions and examples to mine information from narrative texts. We believe that similar methods can be applied to radiology reports to identify and extract critical findings from these reports. However, due to the rarity of such critical events, there is a dearth of manually labeled datasets of critical findings in radiology reports. To overcome this limitation, we train instruction-tuned MISTRAL-based language models in a two-phase weakly supervised fine-tuning setup on unlabeled radiology reports from Mayo Clinic (n=15000). The weakly fine-tuned model is then used to automatically extract critical terms from both internal and external test datasets - Mayo Clinic (n=80) and MIMIC-III (n=123) 1 respectively against the expert-annotation. We also evaluated performance of the models on a large-scale MIMIC-IV reports (n=5000) using automated LLM-aided evaluation metrics - G-eval and Prometheus. We observe that, for both manual and LLM-based evaluations, weakly supervised fine-tuning improves model performance, showing successful task-specific alignment. For community use, we released the trained model with open-source academic license∗

ABSTRACT The definition of the microbiology of pleural space infection has been challenging due to the poor yield of conventional culture. Here, the results of a 16S ribosomal RNA gene PCR/sequencing assay performed on pleural fluid in routine clinical practice between August 2020 and January 2023 were evaluated. Amplified 16S rRNA gene DNA was submitted to Sanger sequencing and/or next-generation sequencing or results were reported as negative, depending on PCR crossing threshold value. In all, 496 pleural fluids were tested at Mayo Clinic Laboratories, with 227 positive results, including 57 from Mayo Clinic patients. Among the 57 Mayo Clinic patients, pleural space infection was community acquired in 48 (84%); Fusobacterium nucleatum group and/or Streptococcus intermedius were detected in 31/57 (54%) cases [including 28/48 (58%) community-acquired cases], with additional facultative and/or anaerobic species also found in various combinations in 17/31 (55%). Results of this study suggest that the most frequent microorganism profile involved in community-acquired pleural space infection may be a combination of F. nucleatum group and/or S. intermedius , with or without other normal microbiota. IMPORTANCE We describe here the most frequent microorganisms detected in community-acquired pleural space infection using a clinically performed sequencing-based assay. We found that the most common detection was the Fusobacterium nucleatum group and/or Streptococcus intermedius , with or without other normal microbiota. We propose the term e-FuSion (effusion with Fusobacterium nucleatum group, Streptococcus intermedius , and other oral normal microbiota) for this entity.

BACKGROUND The management of cystic brain metastases remains challenging, with high recurrence rates following treatment with resection and/or stereotactic radiosurgery (SRS). Tumor resection and adjuvant radiation provide superior outcomes in comparison to those for each therapy alone, but large cystic tumor en bloc removal is difficult. Cyst aspiration can be used to decrease the radiation target volume, enabling safer delivery of a therapeutic radiation dose with improved local tumor control. However, cysts can rapidly recur following aspiration. Herein, the authors present a case in which cyst aspiration, radiation, and resection were combined within a single procedure. OBSERVATIONS During a single anesthesia episode, a 70-year-old female underwent stereotactic cyst aspiration, single-fraction SRS, and resection of a 3.7-cm cystic temporal lobe breast metastasis. The lesion volume exceeded 40 cm 3 before cyst aspiration, decreasing by 62.5% afterward. LESSONS Definitive management of large cystic brain metastases including aspiration, radiation, and resection is feasible under a single anesthesia session. This approach, compared to traditional management, could help minimize challenges associated with large cystic lesions, including recurrence and/or radiation necrosis. https://thejns.org/doi/10.3171/CASE24357

BACKGROUND The authors applied laser interstitial thermal therapy (LITT) to a recurrent skull base chordoma, which has not been previously described. OBSERVATIONS A 63-year-old man was initially diagnosed with an 8-cm destructive clival chordoma, which was aggressively resected endoscopically but recurred despite multiple operations, proton radiation therapy, and chemotherapy. The patient underwent uncomplicated LITT for a subtemporal mass, which palliated the tumor for 10 months. However, it did not ultimately prevent the need for resection, although it may have delayed the surgery. LESSONS This case study demonstrates the feasibility and safety of LITT in treating these typically surgically challenging tumors. https://thejns.org/doi/10.3171/CASE24534

Summary: Sacral reconstruction post tumor resection has historically been executed with the placement of hardware or free tissue transfer. Reconstruction using a vascularized bone graft is an alternative that avoids the complications associated with hardware placement or free tissue transfer. This article describes the first documented case of spinoplastic reconstruction using an iliac crest vascularized bone graft (IC-VBG) after the resection of a sacral ependymoma. This is a case of a 17-year-old boy with a history of a sacral myxopapillary ependymoma. He presented to a local emergency department complaining of 6 months of urinary incontinence and progressive paresthesias affecting the left lower extremity. Magnetic resonance imaging was significant for a lesion located in the extradural spinal canal. Biopsy confirmed a myxopapillary ependymoma, World Health Organization grade II. The initial intervention involved tumor resection with titanium hardware placement. He subsequently required replacement of the titanium hardware with carbon fiber, secondary to the need for surveillance imaging. He underwent harvesting and inset of the IC-VBG at the time of hardware replacement. IC-VBG is a safe and effective modality for spinoplastic reconstruction. It enhances the potential for solid bony union and offers a practical alternative to free bone transfer. This approach provides an asset to add to a reconstructive surgeon’s armamentarium, making it an essential tool for reconstructive surgeons working in conjunction with spinal surgery colleagues.

Background: For patients undergoing abdominal surgery, postoperative pulmonary complications (PPCs) are a major source of morbidity and mortality. The use of point-of-care ultrasonography (POCUS), and specifically POCUS of the lungs, has seen many advancements in recent years. Objectives: We hypothesize that perioperative lung ultrasonography can be used as a predictor for PPCs. Methods: In a Single, 1000 beds, trauma level I medical center, patients presenting for elective intra-abdominal surgery with no severe pulmonary or cardiac diseases were evaluated preoperatively with a standardized 12-point lung ultrasound exam. A second identical exam was performed after surgery in the post-anesthesia care unit. PPCs were also documented. All lung ultrasound exams were presented to a blinded researcher and a lung ultrasound score (LUS) was calculated. Statistical analysis comparing pre- and postoperative LUS and PPC scores were performed. Results: A total of 61 patients were evaluated. The pre-surgery median LUS was 0 (in the range of 0–6) and the post-surgery median LUS was 3 (in the range of 0–14). The pre- to postsurgical LUS delta was 3.4 (standard deviation of 3.3). A postoperative LUS of 6 or more was defined as “high.” A High LUS did not correlate with prolonged post-anesthesia care unit or hospital stay, prolonged oxygen support, or number of desaturation events. Conclusion: For elective abdominal surgery in relatively healthy patients, preoperative LUS usually begins at a normal level and becomes worse after general anesthesia. However, this difference in LUS is not significantly associated with clinically relevant postoperative pulmonary complications such as prolonged oxygen therapy, pneumonia, and noninvasive or invasive mechanical ventilation. Trial registration: Clinicaltrials.gov identifier: NCT05502926. Summary: This paper explores the use of point-of-care ultrasonography as a predictor for postoperative pulmonary complications. The findings suggest that while the lung ultrasound score worsens with general anesthesia, the differences are not significantly associated with postoperative pulmonary complications.

Objective: To compare target artery (TA) outcomes after fenestrated or branched endovascular aortic repair (FB-EVAR) versus open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAAs). Background: Few studies have compared TA outcomes after endovascular incorporation and open reconstruction. Methods: Among consecutive patients who underwent elective OSR or FB-EVAR of TAAAs (2008–2020), we reviewed those who had postoperative imaging studies evaluating TA. Data of FB-EVAR patients were obtained from a prospectively maintained institutional database. TAs included celiac, superior mesenteric, right, and left renal arteries treated during TAAA repairs. The primary endpoint was TA patency (primary and secondary). Results: There were 131 patients (487 TAs) treated by OSR and 350 (1300 TAs) by FB-EVAR. In the OSR group, 440 TAs (90.3%) were reconstructed by bypasses, and 47 (9.7%) by reimplantation. In the FB-EVAR group, 841 TAs (64.7%) were incorporated by fenestrations and 459 (35.3%) by directional branches. Thirty-day TA primary patency rates were not significantly different between FB-EVAR and OSR (99.4%% vs 99.0%, P = 0.36), but the secondary patency rate was higher after FB-EVAR (99.8% vs 99.0%, P = 0.02). Three-year primary patency rates were 95.9% (95% CI: 94.7%–97.2%) and 94.7% (95% CI: 92.2%–97.2%), respectively; secondary patency rates were 98.5% (95% CI: 97.7%–99.2%) and 94.7% (95% CI: 95.7%–99.2%), respectively. There were no significant differences in late primary patency and secondary patency between groups (each P < 0.05). Conclusions: TA primary and secondary patency rates following elective OSR or FB-EVAR were high. Endovascular repair was not associated with loss of primary patency and late secondary patency.

Background: Osteochondritis dissecans (OCD) of the knee is a focal idiopathic alteration of subchondral bone and/or its precursor with risk for instability and disruption of adjacent cartilage. Treatment options focused on preventing premature osteoarthritis vary depending on multiple patient and lesion characteristics, including lesion mobility. Purpose: To differentiate lesion mobility before arthroscopy using a multivariable model that includes patient demographic characteristics and physical examination findings. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Demographic, preoperative physical examination, and radiographic data were collected from a multicenter national prospective cohort of patients with OCD of the knee. Inclusion criteria included patients <19 years of age and patients with arthroscopically confirmed mobility status based on the Research on Osteochondritis Dissecans of the Knee arthroscopy classification. Multivariable logistic regression analysis using stepwise model selection was used to determine factors associated with the likelihood of a mobile versus an immobile lesion. A 75% partition of the data was used for model training, and 25% was used as a validation cohort. Quantitative model fit statistics were computed using the holdout data, including sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC), along with the corresponding 95% CI. Results: A total of 407 patients in the prospective cohort met inclusion criteria, and 62% were male. The mean ± SD age was 13.7 ± 2.2 years, height 161.8 ± 5.3 cm, and weight 59.2 ± 42.2 kg. Arthroscopic evaluation yielded 235 immobile and 172 mobile lesions. Multivariable analysis determined that the best model to predict lesion mobility included chronologic age ≥14 years ( P < .001), effusion on physical examination ( P < .001), and any loss of range of motion on physical examination ( P = .07), while controlling for male sex ( P = .38) and weight >54.4 kg ( P = .12). In the 25% holdout validation sample (n = 102), a sensitivity of 83%, a specificity of 82%, and an AUC of 0.89 (95% CI, 0.82-0.95) were achieved with these predictive factors. Conclusion: Age, effusion, and loss of motion can predict knee OCD lesion mobility at the time of arthroscopy. Education about lesion mobility can help with surgical planning and patient and family counseling.

Background: Adolescents and young adults (AYAs) living with advanced cancer may experience a heightened risk for existential distress. Addressing AYAs’ hopes can stimulate a dialogue about their concerns, values, and goals, provide a path to holistically support their existential needs, and potentially alleviate their distress. This study aimed to evaluate hope's role in a sample of AYAs living with advanced cancer. Method: This study used a Husserlian phenomenology-informed descriptive qualitative research design to elicit AYAs’ experiences with hope while living with advanced cancer. Participants were virtually recruited from an academic medical center and an online non-profit organization. Thematic analyses were performed across the data set to identify final themes. Results: Fifteen AYAs aged 12–21 years diagnosed with advanced hematological (80%) or solid (20%) malignancies participated in this study. A main theme of Simple Supports of Hope with a subtheme of Diversion was identified. Participants described music as a form of diversion, which supported their hope. Participants found listening to music calming and comforting and helped them cope with their distress. Performing music provided a creative outlet for negative feelings associated with cancer treatment. Participants reported creating music transformed and deintensified the treatment environment and helped spread hope to healthcare staff. Discussion: AYAs may intentionally use music to improve emotional expression, empowerment, connection, and coping strategies throughout the treatment process for cancer. Additional research needs to be conducted exploring the use of music interventions such as therapeutic songwriting or compositional music therapy to assist AYAs with building coping strategies during treatment for cancer.