Scholarly Works, Virginia Tech Carilion School of Medicine (VTCSOM)

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  • Prognostic Factors and Nomogram for Choroid Plexus Tumors: A Population-Based Retrospective Surveillance, Epidemiology, and End Results Database Analysis
    Bhutada, Abhishek S.; Adhikari, Srijan; Cuoco, Joshua A.; In, Alexander; Rogers, Cara M.; Jane, John A.; Marvin, Eric A. (MDPI, 2024-01-31)
    Background: Choroid plexus tumors (CPTs) are rare neoplasms found in the central nervous system, comprising 1% of all brain tumors. These tumors include choroid plexus papilloma (CPP), atypical choroid plexus papilloma (aCPP), and choroid plexus carcinoma (CPC). Although gross total resection for choroid plexus papillomas (CPPs) is associated with long-term survival, there is a scarcity of prospective data concerning the role and sequence of neoadjuvant therapy in treating aCPP and CPC. Methods: From the years 2000 to 2019, 679 patients with CPT were identified from the Surveillance, Epidemiology, and End Result (SEER) database. Among these patients, 456 patients had CPP, 75 patients had aCPP, and 142 patients had CPC. Univariate and multivariable Cox proportional hazard models were run to identify variables that had a significant impact on the primary endpoint of overall survival (OS). A predictive nomogram was built for patients with CPC to predict 5-year and 10-year survival probability. Results: Histology was a significant predictor of OS, with 5-year OS rates of 90, 79, and 61% for CPP, aCPP, and CPC, respectively. Older age and African American race were prognostic for worse OS for patients with CPP. Older age was also associated with reduced OS for patients with aCPP. American Indian/Alaskan Native race was linked to poorer OS for patients with CPC. Overall, treatment with gross total resection or subtotal resection had no difference in OS in patients with CPP or aCPP. Meanwhile, in patients with CPC, gross total resection (GTR) was associated with significantly better OS than subtotal resection (STR) only. However, there is no difference in OS between patients that receive GTR and patients that receive STR with adjuvant therapy. The nomogram for CPC considers types of treatments received. It demonstrates acceptable accuracy in estimating survival probability at 5-year and 10-year intervals, with a C-index of 0.608 (95% CI of 0.446 to 0.77). Conclusions: This is the largest study on CPT to date and highlights the optimal treatment strategies for these rare tumors. Overall, there is no difference in OS with GTR vs. STR in CPP or aCPP. Furthermore, OS is equivalent for CPC with GTR and STR plus adjuvant therapy.
  • Noninvasive neuromodulation of subregions of the human insula differentially affect pain processing and heart-rate variability: a within-subjects pseudo-randomized trial
    Legon, Wynn; Strohman, Andrew; In, Alexander; Payne, Brighton (Wolters Kluwer Health, Inc., 2024-02-01)
    The insula is an intriguing target for pain modulation. Unfortunately, it lies deep to the cortex making spatially specific noninvasive access difficult. Here, we leverage the high spatial resolution and deep penetration depth of low-intensity focused ultrasound (LIFU) to nonsurgically modulate the anterior insula (AI) or posterior insula (PI) in humans for effect on subjective pain ratings, electroencephalographic (EEG) contact heat–evoked potentials, as well as autonomic measures including heart-rate variability (HRV). In a within-subjects, repeated-measures, pseudo-randomized trial design, 23 healthy volunteers received brief noxious heat pain stimuli to the dorsum of their right hand during continuous heart-rate, electrodermal, electrocardiography and EEG recording. Low-intensity focused ultrasound was delivered to the AI (anterior short gyrus), PI (posterior longus gyrus), or under an inert Sham condition. The primary outcome measure was pain rating. Low-intensity focused ultrasound to both AI and PI similarly reduced pain ratings but had differential effects on EEG activity. Low-intensity focused ultrasound to PI affected earlier EEG amplitudes, whereas LIFU to AI affected later EEG amplitudes. Only LIFU to the AI affected HRV as indexed by an increase in SD of N-N intervals and mean HRV low-frequency power. Taken together, LIFU is an effective noninvasive method to individually target subregions of the insula in humans for site-specific effects on brain biomarkers of pain processing and autonomic reactivity that translates to reduced perceived pain to a transient heat stimulus.
  • Widespread Community Transmission of Hepatitis A Virus Following an Outbreak at a Local Restaurant-Virginia, September 2021-September 2022
    Helmick, Meagan J.; Morrow, Cynthia B.; White, J. Hope; Bordwine, Paige (Centers for Disease Control and Prevention, 2023-04-07)
    What is already known about this topic? U.S. hepatitis A incidence has been increasing since 2016. What is added by this report? In 2021, a hepatitis A outbreak in Virginia traced to an unvaccinated food handler resulted in 51 cases, 31 hospitalizations, and three deaths. As of September 30, 2022, an additional 98 community hepatitis A cases had been reported in the Roanoke City and Alleghany Health Districts. What are the implications for public health practice? Public health partnerships with businesses and other community partners (e.g., harm reduction programs) might increase hepatitis A vaccination among persons at risk for this infection, while also reducing the stigmatization of hepatitis A-associated risk factors.
  • Delayed presentation of food protein-induced enterocolitis syndrome (FPIES) to okra in a toddler
    Hall, Hunter; Anvari, Sara; Schultz, Fallon; Ojuola, Olubukola; Rider, Nicholas L. (2024-02-03)
    Background: Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E (IgE) -mediated food allergy predominantly observed in infants and characterized by the delayed onset of vomiting following ingestion of a trigger food. An increase in research and clinical consideration of FPIES has led to the discovery of unique deviations from the standard FPIES triggers and presentations. Case presentation: A 34-month-old female patient with a history of consuming okra daily presented to medical attention after developing classic FPIES symptoms to okra beginning at 14-months of age. Conclusions: Recently, awareness about the varied nature of FPIES clinical presentation has come to light. This case is the first to describe FPIES to the fruit okra that developed over a 12-month time span after previously tolerating the food. This case serves to emphasize the importance of understanding the range of FPIES symptoms to improve recognition and expedite best practice recommendations.
  • Changes in Clinical Management Following 14-Day Ambulatory ECG Monitoring Following Emergency Department Evaluation for Unexplained Syncope
    Moore, Andrew B.; Gershon, Colin; Fiske, Christa; Sun, Benjamin; Nazer, Babek; Kea, Bory (Elsevier, 2024-01-23)
  • Neurocognitive Correlates of Clinical Decision Making: A Pilot Study Using Electroencephalography
    Toy, Serkan; Shafiei, Somayeh B.; Ozsoy, Sahin; Abernathy, James; Bozdemir, Eda; Rau, Kristofer K.; Schwengel, Deborah A. (MDPI, 2023-11-30)
    The development of sound clinical reasoning, while essential for optimal patient care, can be quite an elusive process. Researchers typically rely on a self-report or observational measures to study decision making, but clinicians’ reasoning processes may not be apparent to themselves or outside observers. This study explored electroencephalography (EEG) to examine neurocognitive correlates of clinical decision making during a simulated American Board of Anesthesiology-style standardized oral exam. Eight novice anesthesiology residents and eight fellows who had recently passed their board exams were included in the study. Measures included EEG recordings from each participant, demographic information, self-reported cognitive load, and observed performance. To examine neurocognitive correlates of clinical decision making, power spectral density (PSD) and functional connectivity between pairs of EEG channels were analyzed. Although both groups reported similar cognitive load (p = 0.840), fellows outperformed novices based on performance scores (p < 0.001). PSD showed no significant differences between the groups. Several coherence features showed significant differences between fellows and residents, mostly related to the channels within the frontal, between the frontal and parietal, and between the frontal and temporal areas. The functional connectivity patterns found in this study could provide some clues for future hypothesis-driven studies in examining the underlying cognitive processes that lead to better clinical reasoning.
  • Residency Program Directors' Views on Research Conducted During Medical School: A National Survey
    Wolfson, Rachel K.; Fairchild, Paige C.; Bahner, Ingrid; Baxa, Dwayne M.; Birnbaum, Deborah R.; Chaudhry, Sarwat I.; Chretien, Katherine C.; Defranco, Donald B.; Deptola, Amber Z.; Laconte, Leslie E. W.; Lin, Jenny J.; Lee, Leslie Petch; Powers, Maureen A.; Ropson, Ira J.; Sankaran, Saumya M.; Sawarynski, Kara E.; Sozio, Stephen M. (Association of American Medical Colleges, 2023-04-21)
    Purpose: With the United States Medical Licensing Examination Step 1 transition to pass/fail in 2022, uncertainty exists regarding how other residency application components, including research conducted during medical school, will inform interview and ranking decisions. The authors explore program director (PD) views on medical student research, the importance of disseminating that work, and the translatable skill set of research participation. Method: Surveys were distributed to all U.S. residency PDs and remained open from August to November 2021 to query the importance of research participation in assessing applicants, whether certain types of research were more valued, productivity measures that reflect meaningful research participation, and traits for which research serves as a proxy. The survey also queried whether research would be more important without a numeric Step 1 score and the importance of research vs other application components. Results: A total of 885 responses from 393 institutions were received. Ten PDs indicated that research is not considered when reviewing applicants, leaving 875 responses for analysis. Among 873 PDs (2 nonrespondents), 358 (41.0%) replied that meaningful research participation will be more important in offering interviews. A total of 164 of 304 most competitive specialties (53.9%) reported increased research importance compared with 99 of 282 competitive (35.1%) and 95 of 287 least competitive (33.1%) specialties. PDs reported that meaningful research participation demonstrated intellectual curiosity (545 [62.3%]), critical and analytical thinking skills (482 [55.1%]), and self-directed learning skills (455 [52.0%]). PDs from the most competitive specialties were significantly more likely to indicate that they value basic science research vs PDs from the least competitive specialties. Conclusions: This study demonstrates how PDs value research in their review of applicants, what they perceive research represents in an applicant, and how these views are shifting as the Step 1 exam transitions to pass/fail.
  • Protecting Teams Through the Pandemic
    Carver, M. Colette; Frazier, Tricia (2022-04-28)
    Leading with TEAM - mantra Protect our team - Protect our patients - Protect our business Consistent foundational support focused on the team 1. Wellbeing 2. Bidirectional communication 3. Workforce planning and development FCM tailwinds going into pandemic High functioning leadership team at all levels Well positioned clinics geographically - Family Medicine, Internal Medicine, Urgent Care Centers Serve as regional: COVID-19 vaccination hubs COVID-19 Testing and Infusion centers
  • Improving Care Transitions Through Risk Reduction with Machine Learning Support
    Carver, M. Colette; Jones, Nate; Djuric, Dan; Butt, Caroline; Markham, Carla; Brookman, Jeremy; Reece, Chanda; Smith, Jamie (2020-04-15)
    Problem: The ambulatory care management team at Carilion Clinic lacked the necessary tools to demonstrate readmission risk reduction for patients undergoing care transitions. Purpose: This quality improvement project aimed to determine if implementing a real-time workflow management system which supported the prioritization, intervention tracking, and coordination of transitions of care, would result in readmission avoidance through risk reduction. Background: The Accountable Care Strategies team implemented an electronic Transition Tracking Tool (T3), as one aspect of Carilion’s readmission reduction program. Evidence from the literature: Approximately 20% of Medicare beneficiaries are readmitted within 30 days following hospital or facility-based care (Fischer et al., 2014). Many health systems across the country have developed strategies to reduce hospital readmissions after the passage of the Patient Protection and Affordable Care Act and its requirement for the implementation of a Hospital Readmissions Reduction Program (ACA, 2010). While there are a variety of readmission risk stratification tools used to identify patients, the predictive performance of these tools, according to Kansagara et al., (2011), has been marginal due in part to the complex factors contributing to a readmission. These researchers recommend incorporating a larger data set to include social determinants of health (Kansagara et al., 2011). Patient’s social determinants have a significant impact on their readmission risk, thus ambulatory programs which address these factors are essential (Calvillo-King et al., 2013). EBP Question: (1) Is there an impact on readmission for a patient who undergoes risk reduction strategies by a nurse using an automated patient prioritization tool with predictive interventions? Methods: The ambulatory care management team uses a relationship-based model, partnering with patients in self-care which is grounded in Dorothea Orem’s Theory of Self-Care (Petiprin, 2016). The aim is to support personal agency in the achievement of effective self-management. A tool was needed to replace a manual system, which could identify and prioritize at risk patients and track interventions and readmissions. A real-time data system was implemented called T3, it aggregates patients from both in and out of network hospitals. T3 also ingests information from Jvion, a machine learning platform that provides a readmission risk scoring and associated interventions. A dashboard displays patients and their risk scores, along with recommended interventions. Ambulatory nurses working remotely select a patient for outreach, review machine-recommended interventions and use nursing judgement for a patient-centric approach. Readmissions prevented are recorded using specific criteria. Outcomes: On average 2200 patient were managed each month and received risk reduction interventions. Over 11 months 212 patients had a readmission prevented. With the average cost of a hospital stay at $11,200.00, these 212 prevented readmission would have cost well over 2 million dollars. Most importantly the team saved patients from sustaining additional health complications due to a readmission. Implications for practice: Health systems focusing on readmission reduction need to consider using a predictive tool which incorporates social determinants of health and recommends targeted interventions. Prioritizing discharged patients, managing and tracking interventions, and recording readmissions prevented by ambulatory nurses will demonstrate improved quality of care transitions. References: (avail)
  • Metastatic Plasmacytoid Urothelial Carcinoma Masquerading as a Primary Signet Ring Cell Carcinoma of the Duodenum
    Mir, Adil S.; Mouchli, Mohamad; Lebel, David P.; Grider, Douglas J. (Springer, 2023-08)
    Plasmacytoid urothelial carcinoma can histologically mimic gastrointestinal signet ring cell carcinoma, a potential diagnostic pitfall resulting in improper clinical management. We present a rare case of a malignant duodenal ulcer due to metastasis from plasmacytoid urothelial carcinoma. Only by histological and retrospective immunohistochemical comparison with the primary bladder tumor was this revealed as a metastasis from a plasmacytoid urothelial carcinoma. This case report highlights the importance of clinical correlation and comparison with any previous pathology specimens, the limitations of immunohistochemical staining, and the utilization of both old and new immunohistochemical tools when differentiating signet ring cell carcinomas of primary sites versus potential metastases.
  • C-reactive Protein Levels in Patients With Autoimmune Hypothyroidism Before and After Levothyroxine Treatment
    Vudu, Stela; Behnke, Andrew J. (Springer, 2023-12-20)
    Background: Hypothyroidism is one of the most common endocrine disorders. Most patients with hypothyroidism have autoimmune thyroiditis (Hashimoto's), characterized by elevated concentrations of anti-thyroperoxidase (ATPO) antibodies. Both overt hypothyroidism (OH) and subclinical hypothyroidism (SH) have been associated with cardiovascular risk factors, including markers of inflammation. High-sensitivity C-reactive protein (hs-CRP) is a veridical marker of systemic inflammation. Even a minor increase in hs-CRP is considered a cardiovascular risk; therefore, evidence of a beneficial effect of levothyroxine treatment on hs-CRP could be an argument in favor of therapy for SH. Aim: To assess hs-CRP levels in patients with hypothyroidism and evaluate levothyroxine treatment's effect on hs-CRP. Study design: This is a cohort study in which patients with hypothyroidism were evaluated before and after treatment with levothyroxine. Methods: 37 patients (17 with OH and 20 with SH) and 38 healthy controls were included in the study. hs-CRP was measured at the baseline visit, then after 2 and 4 months of levothyroxine therapy at a dose necessary to achieve euthyroidism as evidenced by a normal level of thyroid-stimulating hormone (TSH). Results: hs-CRP was significantly increased in OH (p < 0.001) and SH (p = 0.001) at baseline as compared to controls. hs-CRP significantly decreased in SH (2.2±1.6 mg/L at baseline visit, 1.4±1.1 mg/L after 2 months of levothyroxine treatment, P = 0.017) and tended to decrease in OH (2.3±1.6 mg/L at baseline visit, 1.6±1.1 mg/L after 4 months of levothyroxine treatment, P = 0.067*). Conclusions: Patients with hypothyroidism have increased hs-CRP levels compared to a healthy control group and, thereby, a moderately increased cardiovascular risk. Achievement of euthyroidism by levothyroxine treatment decreased the levels of hs-CRP in patients with hypothyroidism.
  • Proximal femoral replacement using the direct anterior approach to the hip
    Thaler, Martin; Manson, Theodore T.; Holzapfel, Boris Michael; Moskal, Joseph T. (Urban & Vogel, 2022-06)
    Objective: Proximal femoral replacement (PFR) is a salvage procedure originally developed for reconstruction after resection of sarcomas and metastatic cancer. These techniques can also be adapted for the treatment of non-oncologic reconstruction for cases involving massive proximal bone loss. The direct anterior approach (DAA) is readily utilized for revision total hip arthroplasty (THA), but there have been few reports of its use for proximal femoral replacement. Indications: Aseptic, septic femoral implant loosening, periprosthetic femoral fracture, oncologic lesions of the proximal femur. The most common indication for non-oncologic proximal femoral placement is a severe femoral defect Paprosky IIIB or IV. Contraindications: Infection. Surgical technique: In contrast to conventional DAA approaches and extensions, we recommend starting the approach 3 cm lateral to the anterior superior iliac spine and performing a straight incision directed towards the fibular head. After identification and incision of the tensor fasciae lata proximally and the lateral mobilization of the iliotibial tract distally, the vastus lateralis muscle can be retracted medially as far as needed. Special care should be taken to avoid injuries to the branches of the femoral nerve innervating the vastus lateralis muscle. If required, the distal extension of the DAA can continue all the way to the knee to allow implantation of a total femoral replacement. The level of the femoral resection is detected with an x‑ray. In accordance with preoperative planning, the proximal femur is resected. Ream and broach the distal femoral fragment to the femoral canal. With trial implants in place, leg length, anteversion of the implant and hip stability are evaluated. It is crucial to provide robust reattachment of the abductor muscles to the PFR prosthesis. Mesh reinforcement can be used to reinforce the muscular attachment if necessary. Postoperative management: We typically use no hip precautions other than to limit combined external rotation and extension for 6 weeks. In most cases, full weight bearing is possible after surgery. Results: A PFR was performed in 16 patients (mean age: 55.1 years; range 17-84 years) using an extension of the DAA. The indication was primary bone sarcoma in 7 patients, metastatic lesion in 6 patients and massive periprosthetic femoral bone loss in 3 patients. Complications related to the surgery occurred in 2 patients (both were dislocation). Overall, 1 patient required reoperation and 1 patient died because of his disease. Mean follow-up was 34.5 months.
  • Femoral revision with the direct anterior approach
    Thaler, Martin; Corten, Kristoff; Nogler, Michael; Holzapfel, Boris Michael; Moskal, Joseph T. (Urban & Vogel, 2022-06)
    Objective: The advantages of the direct anterior approach (DAA) in primary total hip arthroplasty as a minimally invasive, muscle-sparing, internervous approach are reported by many authors. Therefore, the DAA has become increasingly popular for primary total hip arthroplasty (THA) in recent years, and the number of surgeons using the DAA is steadily increasing. Thus, the question arises whether femoral revisions are possible through the same interval. Indications: Aseptic, septic femoral implant loosening, malalignment, periprosthetic joint infection or periprosthetic femoral fracture. Contraindications: A draining sinus from another approach. Surgical technique: The incision for the primary DAA can be extended distally and proximally. If necessary, two releases can be performed to allow better exposure of the proximal femur. The DAA interval can be extended to the level of the anterior superior iliac spine (ASIS) in order to perform a tensor release. If needed, a release of the external rotators can be performed in addition. If a component cannot be explanted endofemorally, and a Wagner transfemoral osteotomy or an extended trochanteric osteotomy has to be performed, the skin incision needs to be extended distally to maintain access to the femoral diaphysis. Postoperative management: Depending on the indication for the femoral revision, ranging from partial weight bearing in cases of periprosthetic fractures to full weight bearing in cases of aseptic loosening. Results: In all, 50 femoral revisions with a mean age of 65.7 years and a mean follow-up of 2.1 years were investigated. The femoral revision was endofemoral in 41 cases, while a transfemoral approach with a lazy‑S extension was performed in 9 patients. The overall complication rate was 12% (6 complications); 3 patients or 6% of the included patients required reoperations. None of the implanted stems showed a varus or valgus position. There were no cases of mechanical loosening, stem fracture or subsidence. Median WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score before surgery improved significantly from preoperative (52.5) to postoperative (27.2).
  • Revisiting Cemented Femoral Fixation in Hip Arthroplasty
    Khanuja, Harpal; Mekkawy, Kevin; MacMahon, Aoife; McDaniel, Claire; Allen, Donald A.; Moskal, Joseph T. (Lippincott, Williams & Wilkins, 2022-06-01)
    -The primary means of femoral fixation in North America is cementless, and its use is increasing worldwide, despite registry data and recent studies showing a higher risk of periprosthetic fracture and early revision in elderly patients managed with such fixation than in those who have cemented femoral fixation. -Cemented femoral stems have excellent long-term outcomes and a continued role, particularly in elderly patients. -Contrary to historical concerns, recent studies have not shown an increased risk of death with cemented femoral fixation. -The choice of femoral fixation method should be determined by the patient's age, comorbidities, and bone quality. -We recommend considering cemented femoral fixation in patients who are >70 years old (particularly women), in those with Dorr type-C bone or a history of osteoporosis or fragility fractures, or when intraoperative broach stability cannot be obtained.
  • Nitrite reductase activity in F420-dependent sulphite reductase (Fsr) from Methanocaldococcus jannaschii
    Heryakusuma, Christian; Johnson, Eric F.; Purwantini, Endang; Mukhopadhyay, Biswarup (Microbiology Society, 2023-04-20)
    Methanocaldococcus jannaschii (Mj), a hyperthermophilic and evolutionarily deeply rooted methanogenic archaeon from a deep-sea hydrothermal vent, produces F420-dependent sulphite reductase (Fsr) in response to exposure to sulphite. This enzyme allows Mj to detoxify sulphite, a potent inhibitor of methyl coenzyme-M reductase (Mcr), by reducing it to sulphide with reduced coenzyme F420 (F420H2) as an electron donor; Mcr is essential for energy production for a methanogen. Fsr allows Mj to utilize sulphite as a sulphur source. Nitrite is another potent inhibitor of Mcr and is toxic to methanogens. It is reduced by most sulphite reductases. In this study, we report that MjFsr reduced nitrite to ammonia with F420H2 with physiologically relevant K m values (nitrite, 8.9 µM; F420H2, 9.7 µM). The enzyme also reduced hydroxylamine with a K m value of 112.4 µM, indicating that it was an intermediate in the reduction of nitrite to ammonia. These results open the possibility that Mj could use nitrite as a nitrogen source if it is provided at a low concentration of the type that occurs in its habitat.
  • Inhaled Treprostinil in Pulmonary Hypertension Due to COPD: PERFECT study results
    Nathan, Steven; Argula, Rahul; Trivieri, Maria; Aziz, Sameh; Gay, Elizabeth; Medarov, Boris; Parambi, Joseph; Raina, Amresh; Risbano, Michael; Thenappan, Thenappan (2023-12)
    Introduction: Pulmonary hypertension accompanying chronic obstructive pulmonary disease (PH-COPD) is associated with worse outcomes than COPD alone. There are currently no approved therapies to treat PH-COPD. The PERFECT study (NCT03496623) sought to evaluate the safety and efficacy of inhaled treprostinil (iTRE) in this patient population. Methods: Patients with PH-COPD (mean pulmonary artery pressures ≥30 mmHg and pulmonary vascular resistances ≥4 Wood units) were enrolled in a multicentre, randomised (1:1), double-blind, placebo-controlled, 12-week, crossover study. A contingent parallel design was also prespecified and implemented, based on a blinded interim analysis of missing data. Patients received treatment with iTRE up to 12 breaths (72 μg) 4 times daily or placebo. The primary efficacy end point was change in peak 6-minute walk distance (6MWD) at Week 12. Results: In total, 76 patients were randomised, 64 in the original crossover design and 12 in the contingent parallel design; 66 patients received iTRE and 58 received placebo. The study was terminated early at the recommendation of the Data and Safety Monitoring Committee based on the totality of evidence that iTRE increased the risk of serious adverse events and suggestive evidence of an increased risk of mortality. The change in 6MWD was numerically worse with iTRE exposure than with placebo exposure. Conclusions: The risk-benefit observations associated with iTRE in patients with PH-COPD did not support continuation of the PERFECT study. The results of this study do not support iTRE as a viable treatment option in patients with PH-COPD.
  • Endovascular treatment of a ruptured pure arterial malformation and associated dysplastic middle cerebral artery dissecting aneurysm: illustrative case
    Marlow, Christine; Cuoco, Joshua A.; Ravina, Kristine; Sloboda, Cole A.; Entwistle, John J. (Journal of Neurosurgery Publishing Group, 2023-05-22)
    BACKGROUND Pure arterial malformations are characterized as unique cerebrovascular lesions with a dilated, coil-like appearance and tortuous arteries without early venous drainage. Historically, these lesions have been described as incidental findings with a benign natural history. However, pure arterial malformations can rarely demonstrate radiographic progression and develop associated focal aneurysms with an unclear risk of rupture. Whether radiographic progression of these lesions or the presence of an associated aneurysm warrants treatment remains controversial. OBSERVATIONS A 58-year-old male presented with sudden-onset left hemiparesis. Computed tomography revealed a large, acute, right frontotemporoparietal intraparenchymal hemorrhage with underlying irregular curvilinear calcifications. Diagnostic cerebral angiography revealed a dysplastic right middle cerebral artery dissecting aneurysm along the M2 segment associated with a pure arterial malformation, which was treated with endovascular flow diversion in a delayed fashion. LESSONS Pure arterial malformations with associated focal aneurysms may not exhibit a benign natural history as once thought. Intervention should be considered for ruptured pure arterial malformations to mitigate the risk of rerupture. Asymptomatic patients with a pure arterial malformation with an associated aneurysm should at least be followed closely with interval radiographic imaging to evaluate for malformation progression or changes in aneurysmal morphology.
  • Co-occurrence of dural arteriovenous fistula and meningioma: A rare case and systematic review
    Bhutada, Abhishek S.; Adhikari, Srijan; Cuoco, Joshua A.; In, Alexander; Entwistle, John J.; Witcher, Mark R. (Elsevier, 2023-07-01)
    Background: The coexistence of meningioma and dural arteriovenous fistula (dAVF) is a rare, but highly complex condition. Various pathophysiological mechanisms underlie intracranial meningiomas with continuous or distant dAVFs. We describe a case of coexisting meningioma and dAVF with a systematic review of the literature. Result: Including the present case, there are 21 reported cases of coexisting intracranial dAVF and meningioma. The patients’ ages ranged from 23 to 76 years, with a mean age of 61 years. The most common presenting symptom was headache. The dAVFs were commonly located at the transverse-sigmoid sinus (43%) and superior sagittal sinus (24%). The most common meningioma locations were the tentorium and parietal convexity. In 76% of the cases, the meningioma occluded the sinus. The most common dAVF treatment was transcatheter arterial embolization, followed by tumor resection (52%). Among the 20 cases with available outcome data, 90% reported favorable outcomes. Conclusion: This report highlights some of the features of coexisting dAVF and meningioma and presents a systematic review of other reports on this phenomenon. Through an in-depth analysis of the literature, we highlight some of the leading theories regarding the causes of concomitant dAVF and meningiomas. Our report supports one of the leading theories that impaired venous return, whether through the occlusion of sinuses or sinus manipulation during surgery, plays a role in the development of dAVF. Further understanding may help guide future clinical decision-making and surgical planning.
  • National assessment of obstetrics and gynecology and family medicine residents' experiences with CenteringPregnancy group prenatal care
    Place, Jean Marie; Van De Griend, Kristin; Zhang, Mengxi; Schreiner, Melanie; Munroe, Tanya; Crockett, Amy; Ji, Wenyan; Hanlon, Alexandra L. (2023-11-21)
    Objective To examine family medicine (FM) and obstetrician-gynecologist (OB/GYN) residents’ experiences with CenteringPregnancy (CP) group prenatal care (GPNC) as a correlate to perceived likelihood of implementing CP in future practice, as well as knowledge, level of support, and perceived barriers to implementation. Methods We conducted a repeated cross-sectional study annually from 2017 to 2019 with FM and OB/GYN residents from residency programs in the United States licensed to operate CP. We applied adjusted logistic regression models to identify predictors of intentions to engage with CP in future practice. Results Of 212 FM and 176 OB/GYN residents included in analysis, 67.01% of respondents intended to participate as a facilitator in CP in future practice and 51.80% of respondents were willing to talk to decision makers about establishing CP. Both FM and OB/GYN residents who spent more than 15 h engaged with CP and who expressed support towards CP were more likely to participate as a facilitator. FM residents who received residency-based training on CP and who were more familiar with CP reported higher intention to participate as a facilitator, while OB/GYN residents who had higher levels of engagement with CP were more likely to report an intention to participate as a facilitator. Conclusion Engagement with and support towards CP during residency are key factors in residents’ intention to practice CP in the future. To encourage future adoption of CP among residents, consider maximizing resident engagement with the model in hours of exposure and level of engagement, including hosting residency-based trainings on CP for FM residents.
  • Integrating Oral Health into Health Professions School Curricula
    Gill, Stephanie A.; Quinonez, Rocio B.; Deutchman, Mark; Conklin, Charles E.; Rizzolo, Denise; Rabago, David; Haidet, Paul; Silk, Hugh (Taylor & Francis, 2022-07)
    Oral health is essential to human health. Conditions associated with poor oral health involve all organ systems and many major disease categories including infectious disease, cardiovascular disease, chronic pain, cancer, and mental health. Outcomes are also associated with health equity. Medical education organizations including the Association of American Medical Colleges and National Academy of Medicine recommend that oral health be part of medical education. However, oral health is not traditionally included in many medical school, physician assistant, or nurse practitioner curricula. Several challenges explain this exclusion including lack of time, expertise, and prioritization; we therefore provide suggestions for integrating oral health education into the health professions school curriculum. These recommendations offer guidance for enhancing the oral health curriculum across institutions. We include key organizational and foundational steps, strategies to link oral health with existing content, and approaches to achieve curricular sustainability.