Citations

Abstract Drug-resistant epilepsy affects tens of millions of people worldwide and is associated with considerable morbidity and mortality. Thalamic deep brain stimulation and cortical responsive neurostimulation are proven treatments for focal epilepsy. Both have been used to target a range of thalamic nuclei; yet, the roles of these thalamic nuclei in focal seizure generation remain incompletely understood. Thirteen patients with drug-resistant focal epilepsy undergoing intracranial EEG were consented to undergo investigation of thalamocortical networks. Sampled regions included cortical, mesial temporal, and thalamic brain regions. Visual and spectral analyses were performed to identify seizure onset patterns and correlate thalamic and cortical seizure activity. Thalamic ictal discharges were observed in 89% of seizures. Of these, 56% demonstrated synchronous thalamocortical activity with distinct patterns. These onset patterns included hypersynchronous spiking, low-voltage fast activity, ictal baseline shifts, and broadband suppression. Multiple thalamic nuclei were involved in ictal organization and propagation, with the specific nuclei depending on the cortical seizure network. The thalamus plays a crucial role in focal onset seizure generation and propagation, with distinct seizure onset patterns and nuclei involved. These findings support exploring a broader range of thalamic nuclei in epilepsy neurostimulation and have implications for seizure detection settings in intracranial sensing devices.

Importance Currently, there are no standardized outcome domains or measures in clinical trials for facial aging. Heterogeneity in outcome domains and measurement instruments across clinical trials creates difficulty in directly comparing interventions, determining superior therapies, and developing high-quality meta-analyses. Objective To develop a core outcome set (COS) of essential domains to be reported in clinical trials evaluating the efficacy of interventions for facial aging. Evidence Review PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, and CINAHL were searched from September 2005 to September 2015. An updated search of the same databases was performed from September 2015 to February 2026. Studies were included if (1) they were randomized clinical trial or controlled clinical trial in design, (2) they assessed the efficacy or safety of an intervention for facial aging, (3) they were published in English, and (4) they involved human participants. Complementary sources, including patient interviews, were used to capture further relevant outcomes. Two rounds of Delphi surveys, followed by consensus meetings, were used to identify outcome domains considered most important by both patient and physician stakeholders. Findings The final COS consists of 6 outcome domains: (1) overall convenience of treatment; (2) time to return to normal work and social activity; (3) overall assessment of focused area of treatment (at the point in time when treatment is expected to provide peak benefit); (4) duration of treatment effect; (5) severity of persistent local or systemic adverse events, including pigmentary change, skin texture change, delayed healing, scarring, and serious adverse events; and (6) patient satisfaction with treatment. Conclusions and Relevance The 6 outcome domains identified through a Delphi consensus are recommended for reporting in future facial aging trials to ensure that outcomes that matter most to patients and clinicians are measured and that results are comparable across interventions.

Objective: To evaluate the institutional learning curve of robotic liver resection (RLR), its association with surgical complexity and outcomes in an international multicenter cohort. Summary of Background Data: RLR is increasingly adopted worldwide, but the dynamics of the learning process and its impact on surgical outcomes remain poorly defined. Methods: This international, multicenter, retrospective cohort study included consecutive patients who underwent RLR between 06/2013 and 12/2024 across 22 expert centers. Based on the first 150 cases at each center, three phases were used to define the learning curve: operative time for competency, major complications for proficiency, and textbook outcome for mastery. Risk-adjusted generalized additive models were used to assess the learning process. Benchmark performance was compared to international reference values. Results: Among 2,331 patients, the most common indications were hepatocellular carcinoma (36%), benign lesions (23%) and colorectal liver metastases (21%). Operative time decreased after achieving competency (case #62), from 240 to 220 minutes ( P <0.001). Major morbidity reached a plateau during the proficiency phase (cases #63–138; 9% vs. 11%, P =0.144), while progression to mastery (cases #139–150) was associated with a higher rate of textbook outcome (76% vs. 87%, P =0.021). In contrast, conversion (5.1% vs. 4.9% vs. 2%), bile leak (4.0% vs. 5.3% vs. 3.8%), and 90-day mortality (0.7% vs. 0.9% vs. 0.9%) remained low and stable across all learning phases. Importantly, benchmark criteria for operative time, hospital stay, and textbook outcome were met across all complexity groups, including during the early learning phase. Conclusions: Robotic liver surgery shows progressive outcome improvement with early achievement of benchmark-level results and stable performance across increasing complexity. These findings indicate that, in experienced centers, RLR can be safely implemented and integrated into clinical practice, supporting its key role in modern hepatobiliary surgery.

Objective: Characterize pathogenic variants, rates of mosaicism, genetic testing yield, and disease severity among patients with NF2-related schwannomatosis dichotomized by diagnosis before or after the age of 30. Study design: Retrospective analysis. Setting: Tertiary referral center multidisciplinary NF2 clinic from 2021 to 2024. Patients: Patients with NF2-related schwannomatosis. Intervention: Next-generation sequencing. Main outcome measure: Rates of mosaicism, genetic testing rates and yield, and overall disease severity by tumor burden. Results: From 2021 to 2024, there were 32 patients ≥30 years of age and 39 patients diagnosed at younger ages. Patients diagnosed ≥30 years exhibited decreased likelihood of receiving genetic testing (53% vs. 85%; P =0.009) and decreased genetic yield (defined as identification of a pathogenic genetic variant in those undergoing testing; 65% vs. 85%; P =0.20). Both age groups demonstrated similar rates of pathogenic variant type with loss-of-function being the predominant variant detected in 73% vs. 67%, for ≥30 vs. <30 years of age; P =0.90. Those ≥30 years harbored fewer number of average anatomic regions involved by tumor (2.3 vs. 3.4; P <0.001) and decreased total number of tumors (7 vs. 12; P <0.001). Conclusions: Patients diagnosed with NF2-related schwannomatosis at age ≥30 years exhibited reduced disease severity compared with those diagnosed at a younger age despite harboring similar distributions of genetic pathogenic variants inclusive of loss-of-function pathogenic variants. These observations emphasize the importance of considering patient age in addition to genetic testing for diagnostic framing tailored to patients’ biology and clinical context to optimize care in the setting of NF2-related schwannomatosis.

ABSTRACT Background Cerebrospinal fluid (CSF) leak after retrosigmoid vestibular schwannoma resection remains a challenging complication. Historically, surgeons reopened the prior retrosigmoid incision for transmastoid repair because the safety of creating a separate postauricular incision was uncertain, with concerns regarding wound breakdown and infection. However, limited data support this practice, and a focused mastoid incision may offer improved access and patient tolerance. This study evaluated wound healing outcomes following transmastoid repair using a new postauricular incision for persistent CSF leak after retrosigmoid surgery in patients without serviceable hearing. Methods We retrospectively reviewed 27 patients who underwent transmastoid repair for persistent postoperative CSF leak after retrosigmoid craniotomy for vestibular schwannoma (2000–2025). Demographics, operative details, timing of leak diagnosis and repair, wound complications, readmissions, antibiotic use, and culture results were analyzed. Results Median age was 48 years (IQR 41–56); 67% were male, and mean BMI was 29.0 kg/m 2 . Mastoid obliteration was performed in 96%, with fat grafting in 93%. A new postauricular incision was used in all cases. Median time to leak diagnosis was 13 days (IQR 4–79), and median time to repair was 2 days (IQR 1–5). One patient (3.7%) developed a superficial wound abscess; no dehiscence or flap necrosis occurred. At median follow‐up of 34 months (IQR 2.9–87.7), all wounds were healed. CSF leak recurred in two patients (7.4%) and three (11.1%) required reoperation. Conclusion A separate postauricular incision for transmastoid CSF leak repair was not associated with increased wound morbidity. Durable wound healing was achieved in all patients, with 93% legal control, supporting this anatomy‐driven approach. Level of Evidence 4

Background: Posterior medial meniscus root tears (PMMRTs) are frequently observed injuries that alter tibiofemoral biomechanics, yet the long-term outcomes are poorly described. Purpose: To perform a systematic review and meta-analysis of the current literature on long-term clinical and radiographic outcomes of operatively managed PMMRTs. Study Design: Meta-analysis and systematic review; Level of evidence, 4. Methods: A systematic review was performed with the inclusion criteria of English-language studies, diagnosis of PMMRT on magnetic resonance imaging, and minimum 5-year radiographic or patient-reported outcome (PRO) metrics. Data analysis included management strategy, surgical technique, meniscal extrusion, medial joint space, PROs, and radiographic measurements. Failure was defined as conversion to arthroplasty, subsequent partial medial meniscectomy (PMM) and/or proximal tibial osteotomy, or clinical failure on PROs. Continuous outcome variables were analyzed with a random effects meta-analysis of mean differences. Chi-square meta-analysis was also used to analyze categorical variables. Results: Twelve studies were identified with >5-year follow-up after PMMRT (mean ± SD, 84.1 ± 11.0 months). Five studies performed PMM, 6 performed medial meniscus root repair (MMR), and 1 utilized either meniscectomy or repair. There were 797 total patients (female, n = 667; 83.7%), with mean ages ranging from 47.2 to 65. Both interventions showed significant PRO improvements after surgery: PMM (pre- vs postoperative Lysholm, 56.1 vs 68.2; P < .01) and MMR (Lysholm, 52.1 vs 83.1; International Knee Documentation Committee [IKDC], 40.0 vs 72.8; P < .01). MMR had significantly lower Kellgren-Lawrence grades (PMM vs MMR, 2.4 vs 1.8; P < .01) and superior IKDC scores (46.5 vs 72.8; P < .01) as compared with PMM. Additionally, PMM had a significantly higher failure rate (23% vs 5.3%) and conversion to knee arthroplasty (20.5% vs 3.5%) as compared with MMR, with odds ratios of 9.8 and 10.2, respectively. Conclusion: This systematic review and meta-analysis of studies with >5-year minimum follow-up found that PMM was associated with a 10-fold increase in clinical failure and conversion to knee arthroplasty relative to MMR in observational studies. In addition, MMR demonstrated superior Kellgren-Lawrence grades and IKDC scores as compared with PMM. The findings of the current analysis suggest that MMR is associated with superior outcomes as compared with PMM at mid- to long-term follow-up.

Acute myeloid leukemia (AML) is a heterogeneous hematologic malignancy characterized by the clonal expansion of myeloid blasts in the peripheral blood, bone marrow, and/or other tissues. It is the most common form of acute leukemia among adults and accounts for the largest number of annual deaths from leukemias in the United States. 1 The NCCN Guidelines Panel for AML convenes annually to update recommendations for the diagnosis and treatment of AML in adults. These recommendations are based on a review of recently published clinical trials that have led to significant improvements in treatment or have yielded new information regarding biologic factors that may have prognostic importance. These NCCN Guidelines Insights summarize the panel’s most recent recommendations regarding the monitoring and management of measurable (minimal) residual disease.