bluuebunny/crossref_metadata_2025_split huggingface dataset:
681 Postoperative Muscle Relaxant Use Associated With Increased Risk of Delirium Following Lumbar Spinal Fusion
Authors: Piscopo Anthony , Perez Eli , Woodroffe Royce 
Published: March 2023

INTRODUCTION:
Muscle relaxants including cyclobenzaprine and baclofen are frequently utilized in pain management following spine surgery as part of enhanced recovery after surgery (ERAS) protocols. These medications are associated with anticholinergic and central nervous system side effects and are used with caution in outpatient treatment for those at high-risk of delirium, especially the elderly. Literature investigating their association with delirium in the postoperative setting has not been described.

METHODS:
Patients over age 65 undergoing elective posterior lumbar fusion between 2017 and 2021 at the senior author’s institution were retrospectively reviewed. Variables collected included patient demographics as well as whether subjects received postoperative administration of baclofen and/or cyclobenzaprine on postoperative day 1 as part of a multimodal analgesia regimen. Doubly-robust inverse probability weighting (IPW) with cox-regression was used to evaluate the incidence of postoperative delirium between groups.

RESULTS:
Five-hundred and thirty-one patients were included in the analysis. Incidence of delirium in those who received postoperative muscle relaxants was 17.6% (44/250) compared to 11.4% (32/281) in the control group who did not (p = 0.001). Doubly-robust IPW analysis found patients who received muscle relaxants were at a 2.07 (95% CI: 1.18-3.63) times increased risk of delirium compared to controls (p = 0.015). Postoperative time to delirium onset was similar between groups (3.0 vs 3.1 days; p = 0.916) while the average duration of delirium was significantly longer in those who received postoperative muscle relaxants (2.5 vs 1.6 days; p = 0.008).

CONCLUSIONS:
Postoperative muscle relaxant use was associated with a higher risk of delirium in elderly adults following lumbar spinal fusion. Although muscle relaxants may assist with postoperative pain control as part of ERAS protocols while minimizing opioid administration, their side effect profile should be considered in patients at high risk of postoperative delirium.
747 Operative Objectives—A Pilot Study
Authors: Khalid Syed Ibad , Kwasnicki Amanda M. , Charbel Fady T. 
Published: March 2023

INTRODUCTION:
Surgical graduate medical education requires residents to learn a wide array of skills and apply them practically in a progressively independent manner, ultimately allowing them to practice independently. We devised "Operative-Objectives" as a tool to define the learning goals for each resident at a particular epoch of their training. This approach is operationalized, measurable, and consistently carried over time.

METHODS:
The Residents at a neurosurgical training program set their "Operative-Objectives" at the beginning of each 3-month rotation. These goals were then reviewed by the Program Director (PD) and faculty and appropriately tailored and finalized--forming a compact between residents and faculty whereby their commitment to the learning and teaching objectives are defined. The outcomes are reviewed with the PD following each rotation and scored. Residents and faculty were provided a pre-and post-implementation survey that sought to understand the impact of implementing "Operative-Objectives" on resident preparedness, objectives for improvement, resident satisfaction with, and objective improvement in resident's surgical skills.

RESULTS:
A total of eight residents and five faculty completed both a pre-and post-implementation survey. Residents reported significantly increased case preparedness (p = .048), ability to track improvement (p = .044), clear objectives for improvement (p = .021), and satisfaction with improvement in surgical skill (p = .044). The faculty reported a significant increase in resident preparedness for surgery (p = .049), ability to track improvement (p=.044), focus for improvement (p=.033), and goals for improvement (p = .033).

CONCLUSIONS:
"Operative Objectives" provide a focused delineation and tracking of a resident's surgical learning at the intersection of three vectors: level of training, location, and ability. The deliverables are measurable. They can be followed over time and allow for an organized and focused framework for improvement and feedback. As such, they can significantly improve the learning skills of the residents as well as the teaching abilities of the faculty.
767 Electrophysiological Analysis of Traumatic Optic Neuropathy in Patients with Suspected Traumatic Brain Injury: A Prospective Cohort Study
Authors: Lucke-Wold Brandon , Carter Lea , Zwerling Charles 
Published: March 2023

INTRODUCTION:
Traumatic optic neuropathy (TON) can cause persistent visual deficits and is a known sequala of traumatic brain injury (TBI). Little is known regarding appropriate diagnosis, management, and treatment.

METHODS:
We performed a prospective cohort study with 356 active military personnel using electrophysiological visual evoked potential (VEP) testing for TON in the context of known or suspected TBI. We utilized a new VEP protocol that included kinetic and static visual field testing to uncover occult cases of TON previously missed in the current disability examination. This was done to incorporate patients with borderline concussive cases that do not meet current diagnosis of mild, moderate, or severe TBI by the Veteran’s Disability Exam.

RESULTS:
80 patients were diagnosed with TON. Average age of TON patients was 37.4 years, with most patients being male. Of those patients with TON, 45% had reported TBI, whereas an additional 54% had suspected history of concussion. Patients presented with bilateral TON (65.8%, n = 52), while unilateral TON cases occurred less frequently (35.4%, n=28). Visual field defects were apparent in both static and kinetic visual field testing in 54% of cases. VEP sensitivity in our study was 88%. Military parachute jumpers (paratroopers) represented the highest risk group for undiagnosed TBI and TON.

CONCLUSIONS:
We recommend periodic static and kinetic visual field testing in high-risk individuals working in fields with high concussion rates. This allows implementation of treatment early to avoid decrements in visual acuity. By instituting our protocol, we can detect visual deficits early in our TBI patients and direct to appropriate treatment centers.
769 In Vivo Evaluation of Spinal Cord Perfusion Using Contrast-Enhanced Transcutaneous Ultrasound
Authors: Shaaya Elias , Leary Owen P. , Sastry Rahul , Zhu Michelle , Persad-Paisley Elijah , Seidler Michael , Beland Michael , Fridley Jared 
Published: March 2023

INTRODUCTION:
Ultrasound (US) imaging is cheap, portable, and widely available. It has been used in multiple medical disciplines, both as a means of diagnosis and therapy. Developing US as a platform for spinal cord perfusion monitoring in patients with spinal cord injury (SCI) would provide a cheap, accessible, and real-time platform for managing spinal cord perfusion in the acute setting.

METHODS:
Four patients with previous cervical decompression and instrumentation were evaluated at a single center with transcutaneous US. We included adult patients with at least 2 levels of continuous cervical laminectomies greater than 3 months prior to US and no history of SCI. The first two patients underwent US imaging without contrast and the second two patients underwent contrast-enhanced US imaging with Lumason, a microbubble agent. Imaging was performed by a board-certified radiologist with US expertise using a General Electric (GE) Logiq E10 ultrasound scanner ans a high frequency linear transducer. The study was approved by the institutional ethics committee.

RESULTS:
In the non-contrast study (n = 2), the dura, spinal cord, and vertebral body were apparent on US. Application of Doppler was insufficient to discern intramedullary perfusion, so contrast-enhanced ultrasound was pursued (n = 2). With contrast, anatomic structures were again visible, and we were able to quantify differential spinal cord perfusion within and between cross-sectional sections of the cord. We demonstrated spinal cord hemodynamic perfusion by measuring peak signal intensity and the time to peak signal intensity after microbubble contrast injection. Then, a time-intensity curve was created and the area under the curve was calculated as a surrogate of spinal cord perfusion.

CONCLUSIONS:
Contrast-enhanced US is a viable platform for monitoring spinal cord perfusion in patients who have undergone prior cervical laminectomies.
770 Gastrostomy Sequence With Ventriculoperitoneal Shunting—Does it Matter?
Authors: Khalid Syed Ibad , Maynard Marquis , Mehta Ankit Indravadan 
Published: March 2023

INTRODUCTION:
Patients who suffer neurologic injury that require ventriculoperitoneal shunt(VPS) placement often also require gastrostomy procedures for feeding access and nutritional support. The timing of these procedures in relation to each other has been debated in the literature, largely steaming from a proposed risk of infection and displacement resulting in a need for revision related to the presence of a gastrostomy.

METHODS:
In an all-payor database, patients undergoing index gastrostomy procedures and VPS placement between 1/2010-10/2020 were identified. Patients were stratified as undergoing gastrostomy placement before, on the same day as, and following the placement of a shunt. The primary outcome of the study was rates of revision All outcomes were evaluated within 30-months following index-shunting. Patients were matched based upon logistic-regression models that evaluated the independent effects of patient and procedural factors on the primary-outcome.

RESULTS:
A total of 4,290-patients were identified as undergoing VPS and gastrostomy procedures. Following a 1:1:1-match procedure, 852-patient records were analyzed. Patients undergoing gastrostomy and VPS on the same day or gastrostomy procedures before VPS (Odds Ratio [OR] 0.55, 95% Confidence Interval [CI] 0.33-0.91 vs. OR 0.60, 95% CI 0.36-0.97, respectively) were observed to have significantly lower rates of revision at 30-months following index shunting when compared to those patients who underwent gastrostomy placement after VPS. No significant differences were noted in rates of infection, mechanical complications, g-tube infections, or shunt displacement between the three approaches.

CONCLUSIONS:
Patients undergoing shunting and gastrostomy tube placement procedures may benefit from undergoing the procedures at the same time as patients undergoing these procedures at the same time are at a decreased risk of repeat requirement for anesthesia reduced rates of VPS revision following observed in comparison to patients undergoing gastrostomy placement after VPS.
772 Re-examining the Role of Post-Operative ICU Admission for Patients Undergoing Elective Craniotomy: A Systematic Review
Authors: Azad Tej D. , Shah Pavan P. , Kannapadi Nivedha , Rincon Torroella Jordina N. , Xia Yuanxuan , Bernhardt Lydia , Hansen Landon John , Materi Joshua , Raj Divyaansh , Jackson Christopher Mitchell , Mukherjee Raj , Gallia Gary L. , Weingart Jon , Suarez Jose , Brem Henry , Bettegowda Chetan 
Published: March 2023

INTRODUCTION:
The standard-of-care for post-operative care following elective craniotomy has historically been intensive care unit (ICU) admission. However, recent literature interrogating complications and interventions during this post-operative ICU stay suggests that all patients may not require this level of care. Thus, hospitals began implementing non-ICU post-operative care pathways for elective craniotomy.

METHODS:
A systematic review of the PubMed database was performed following PRISMA guidelines from database inception through August 2021. Included studies were published in peer-reviewed journals, in English, and described outcomes for patients undergoing elective craniotomies without post-operative ICU care. Data regarding study design, patient characteristics, and post-operative care pathways was extracted independently by two authors. Quality and risk of bias were evaluated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence tool and Risk Of Bias In Non-Randomized Studies—of Interventions tool, respectively.

RESULTS:
In total, 1,131 unique papers were identified through the database search, with 27 meeting inclusion criteria. Included articles were published from 2001-2021 and included non-ICU inpatient care and same-day discharge pathways. Overall, the studies demonstrated that post-operative non-ICU care for elective craniotomies led to length of stay reduction ranging from 6 hours to 4 days and notable cost reductions. Across 13 studies, 53 of the 2,469 (2.1%) patients intended for post-operative management in a non-ICU setting required subsequent care escalation.

CONCLUSIONS:
Overall, these studies suggest that non-ICU care pathways for appropriately selected post-craniotomy patients may represent a meaningful opportunity to improve care value. However, included studies varied greatly in patient selection, post-operative care protocol, and outcomes reporting. Standardization and multi-institutional collaboration are needed to draw definitive conclusions regarding non-ICU post-operative care for elective craniotomy.
774 Prognostication of Civilian Gunshot Wounds to the Head: Internal Validation of the Baylor Score
Authors: Gopakumar Sricharan , Anand Adrish , McDonald Malcolm F. , Cruz-Navarro Jovany , Karas Patrick J. , Gopinath Shankar Prakash 
Published: March 2023

INTRODUCTION:
Early prognostication of patients with gunshot wounds to the head (GSWH) can identify patients who may benefit from aggressive management. The Baylor score uses patient age, pupil reactivity, Glasgow Coma Scale, and bullet trajectory at initial presentation to predict mortality and functional status at six months and performed well when recently assessed at a separate level 1 trauma center demonstrating external validation of the score.

METHODS:
Retrospective chart review of patients with GSWH treated at an academic level 1 trauma center between 2008 and 2022 was performed with Baylor score calculated for each patient. Accuracy of the Baylor score in predicting mortality and good functional outcome (Glasgow Outcome Scale score of 4 or 5) was assessed using receiver operating characteristic (ROC) curves and area under the curve (AUC) as measures of performance.

RESULTS:
A total of 405 patients with GSWH were identified over the 14-year study period (mean age 31.5 years, 88.9% male, 19.5% white). 225 (55.6%) patients died, while 145 (35.8%) had favorable functional outcomes. Mortality rates ranged from 8% for Baylor score 0 to 97% for Baylor score 5, and good functional outcomes ranged from 15% for Baylor score 3 to 87% for Baylor score 0. Baylor score demonstrated good accuracy in prognosticating both mortality (AUC = 0.85) and good functional outcome (AUC = 0.90), though scores 0-2 underestimated favorable outcomes and scores 3-5 underestimated mortality.

CONCLUSIONS:
The Baylor score is a valuable tool for prognosticating GSWH survival and functional outcome and may aid in guiding treatment and family-centered discussions regarding patient prognosis earlier in the hospital course.
775 The Effect of Anti-Seizure Medication Administration on Mortality and Early Post Traumatic Seizures In Critically Ill Older Adults With Traumatic Brain Injury
Authors: Glaser Adam , Kanter John , Martinez-Camblor Pablo , Buhl Lauren , Anderson Matthew , Pannu Ameeka , Shaefi Shahzad , Taenzer Andreas , Boone Myles Dustin 
Published: March 2023

INTRODUCTION:
Older adults (≥65-years) are an understudied and growing TBI population. Guidelines support prophylactic antiseizure medication (ASM) to reduce early posttraumatic seizures (ePTS) (within 7-days of injury) in severe TBI. Whether ASM decreases mortality or ePTS in this population remains unclear. This study assesses association between ASM administration, mortality, and seizure in older TBI patients.

METHODS:
This retrospective cohort study utilized data from the Massachusetts Institute of Technology, Medical Information Mart for Intensive Care-III (MIMIC). Our cohort included patients 65-years or older. Primary exposure was early ASM administration in TBI patients admitted to an ICU at a Level 1 trauma center from 2001-2012. A double-robust inverse propensity scale weighted model based on proportional hazard and logistic regression models assessed the association between ASM administration and risk of death within 7-days of admission.

RESULTS:
Of 1,145 patients, 783 (68.4%) received ASM within the first 24 hours. TBI severity, classified by Glasgow Coma Score (GCS), was predominantly mild (71.2%) followed by moderate (16.8%), and severe (11.3%). Patients who received ASM were less likely to have died at 7-days (adjusted Death HR = 0.48 [95% CI 0.28–0.88] P = 0.005), at 30 days (adjusted HR 0.67 [0.45–0.99] P = 0.045) and at one year (adjusted HR 0.72 [0.54–0.97] P = 0.029). There was no difference in seizure (adjusted Seizure OR 1.18 [0.61–2.26] compared with those who did not receive ASM.

CONCLUSIONS:
Early ASM administration was associated with reduced mortality at 7-days, 30-days, and one-year, but did not affect early seizure risk. This observed benefit in older adults with all TBI severity suggest broader recommendations for ASM use.
793 Sole Arterial Versus Venous Compression in Trigeminal Neuralgia
Authors: Xu Risheng , Nair Sumil , Materi Joshua , So Raymond , Huang Judy , Lim Michael , Bettegowda Chetan 
Published: March 2023

INTRODUCTION:
The majority of trigeminal neuralgia (TN) patients present with trigeminal nerve compression from the superior cerebellar artery. However, pain outcomes in patients with sole venous compression are not well understood.

METHODS:
We retrospectively reviewed 1020 patients undergoing microvascular decompression at our institution, identifying patients with either sole arterial or venous trigeminal nerve compression. We dichotomized patients into arterial or venous compression groups and obtained presenting characteristics, length of stay, and postoperative complications for each case. Pain outcomes were collected for each patient preoperatively and immediately postoperatively, in addition at 3-month, 6-month, 1 year, and >1 year follow up for each case via Barrow Neurological Index (BNI) pain scores. Statistical differences were calculated via Chi-squared tests and t-tests.

RESULTS:
Of 1020 patients, 648 (63.5%) had either sole arterial or venous compression of the trigeminal nerve. 514 of these cases demonstrated arterial compression, as opposed to 134 with only venous compression. Patients in the venous compression group were significantly younger than those in the arterial group. There were no significant differences in presenting comorbidities, ICU admission, length of stay, and postoperative complications between groups. Compared to the arterial compression group, patients with sole venous compression demonstrated significantly worse preoperative (p < 0.001), 3-month follow-up (p = 0.001), 6-month follow-up (p < 0.001), 1-year follow-up (p =< 0.001), and >1-year follow-up BNI scores (p = 0.001). Patients with venous compression were more likely to have recurrent pain (p = 0.047) and demonstrated significantly lower time to recurrence than the arterial compression group (p = 0.001).

CONCLUSIONS:
Patients with sole venous compression of the trigeminal nerve are more likely to have worse pain outcomes following MVD compared to those with only arterial compression, including both likelihood of pain recurrence, and time to recurrence
808 Analysis of Medulloblastomas Subgroups in Pediatric Patients in Latin-America
Authors: Passinho Juliana , Purificacao Junior Antonio F. , Oliveira Renato Guedes , Gorender Ethel , Waldir Beira Renato Melaragno , Carvalho Laube Kaito Alves , Manfroi Gregori , Rehder Roberta , Epelman Sidnei 
Published: March 2023

INTRODUCTION:
The 4 groups molecular-based classification of medulloblastomas is widely accepted. However, technology inaccessibility and low-quality formalin-fixed and paraffin-embedded (FFPE) samples, unable its application for most Latin-American cancer centers.

METHODS:
The goal of this study was to perform a feasibility analysis based on 18 mRNA expression by qPCR integrated with immunohistochemistry (IH) and fluorescent hybridization in situ (FISH) (c-MYC, n-MYC and monosomy 6) for molecular stratification to create an International Treatment Protocol at a low cost for low-income centers.

RESULTS:
Fifty-four FFPE samples were classified according to histologic and molecular aspects. Classic medulloblastoma was the commonest histology (53.7%), followed by desmoplastic/extensive nodularity (24.1%), NOS (16,7%) and anaplastic (5,6%). IH markers classified patients in three groups (WNT, SHH and non-WNT/non-SHH) in 98% of cases. PCR-based method confirmed results from IH in 81.5%. Additionally, it detected WNT activation in 2 more patients, previously classified as SHH. For both cases, the presence of monosomy 6 confirmed WNT subgroup. The integration of these three techniques resulted in the following frequencies: WNT (13.0%), SHH (38.9%), group 3 (9.3%), group 4 (20.3%) and non-WNT/non-SHH (18.5%). From 40 patients with clinical follow-up available, 3-year overall survival (n = 40) for low, intermediate and high-risk groups were 100%, 60% and 20%, respectively (p < 0.05), based only in molecular criteria, which confirmed the prognostic importance of this method at a low cost.

CONCLUSIONS:
The prognosis of the treatment of medulloblastomas has changed after novel studies on the molecular subgroups and the introduction of target-based therapy. The current protocol will enable different centers to implement treatment based on the knowledge of molecular subgroups.
834 Inhibition of the Epileptic Engram Prevents Seizures in a Mouse Model of Temporal Lobe Epilepsy
Authors: Harward Stephen C. , Clark Katie , Shalita Chidyaonga , Lin Thiri , McNamara Jim O. 
Published: March 2023

INTRODUCTION:
The cellular basis of temporal lobe epilepsy (TLE) remains elusive and consequently has hindered efforts to develop novel therapies. Similar challenges have plagued the field of learning and memory until recent work identified plasticity of a subset of neurons in a multi-focal network as the cellular source for memory (the memory engram). Building on these results, we ask if an engram exists for TLE and if it can be targeted to modulate the epileptic phenotype?

METHODS:
We used the intra-amygdala kainic acid status-epilepticus (SE) model in which a brief episode of SE results in spontaneous seizures days later. To identify cells active during epileptogenesis and thus possibly comprising the engram, we performed immunohistochemistry for the immediate early gene product c-Fos (a marker of cellular activity) at various time points after SE (1 to 96 hours). To modulate the persistently active cells, we used a chemical-genetic approach to first label these cells with an inhibitory DREADD (designer receptors exclusively activated by designer drugs) and then inhibit their activity with clozapine-N-oxide (a small molecular activator of DREADDs).

RESULTS:
We found a pattern of c-Fos expression that first appears after SE in the dentate gyrus, begins to localize in subsets of CA3 and CA1 pyramidal neurons by 12 hours, and then persists in these cells for approximately 72 hours. With our chemical-genetic approach, we successfully labeled the cells active after SE with an inhibitory DREADD and then silenced their activity once the animals were epileptic. Such silencing proved effective in significantly reducing the occurrence of subsequent seizure activity.

CONCLUSIONS:
Following an epilepsy-inducing insult, a subset of hippocampal neurons remains persistently active for several days. Subsequent inhibition of these neurons in epileptic animals prevents seizures, consistent with them comprising the epileptic engram.