Major Deficits Research Articles

Delays in diagnosis and treatment initiation of ATTR cardiac amyloidosis: a real-world data analysis

Abstract Introduction Cardiac amyloidosis (CA) is a serious condition characterized by the accumulation of abnormal protein deposits in the heart muscle, leading to functional impairments and, ultimately, heart failure. Transthyretin amyloid cardiomyopathy (ATTR-CM) is the most common form encountered in CA diagnosis with previously underestimated prevalence. ATTR-CM poses a diagnostic challenge, with a substantial number of cases diagnosed late and at advanced stages. The availability of specific pharmacological treatment using the transthyretin-stabilizer tafamidis further emphasizes the need for timely diagnosis. Here, we aim to assess delays in diagnosis and initiation of therapy in a real-world collective of patients with ATTR-CM. Methods All individuals diagnosed from 01/2018 to 05/2023 with ATTR-CM at our university hospital, Germany, were systematically assessed for eligibility in this study. Specifically, we enrolled patients who were undergoing transthyretin stabilizer therapy. The investigation aimed to determine the duration, in days, from the initial suspicion of heart disease to the definitive diagnosis of ATTR-CM. It was also investigated whether the diagnosis of ATTR-CM was made more quickly over time as awareness increased. Additionally, the study assessed the time elapsed until patients received pharmacological therapy following the confirmed diagnosis. The study was approved by the local ethics committee (23-11500-BO). Results After screening of 194 consecutive patients, 154 were included in the analysis, while 40 patients were excluded due to insufficient records. The results of this study reveal that a median of 300 (113-962) days elapsed from the initial suspicion of amyloidosis to the final confirmation. Initial indications of CA often presented as nonspecific symptoms such as unclear dyspnea (16.2% n=25), abnormal echocardiography (75.3% n=116), or, in rare cases, incidental findings (8.4% n=13). Following the diagnosis, an additional median of 84 (46-163.5) days passed before the first prescription of a transthyretin stabilizer. To assess an improvement of ATTR-CM diagnosis over time, we stratified the data into tertiles by date of first diagnosis. The results showed a gradually decrease in medium time to diagnosis of 466 (181-1035) days in the earliest tertile (2018-2019) to 389 (141-1508) days in the most recent tertile (2022-2023) (p<0.001). Conclusion This study shows a major healthcare deficit and underscores the medical need for improved screening procedures and diagnostic modalities to expedite the timely diagnosis of CA, as early identification of the condition is crucial for enhancing the quality of life for patients and preventing life-threatening complications.

Outcomes and complications of vertical parasagittal hemispherotomy in children: a nationwide population-based study.

The goal of this study was to assess the complications associated with vertical parasagittal hemispherotomy (VPH), the impact of incomplete disconnection on long-term seizure freedom, and how VPH impacts cognitive development. A retrospective evaluation was performed in all patients who had undergone VPH during 1991-2022 at the authors' institution. Two-year follow-up data were available for 45 patients, and there were 6-month data for 3 more. All available postoperative MRI studies (31/48, 64.6%) were reviewed. Before 2010, postoperative MRI was only performed if seizures recurred. Primary VPH led to Engel class I in 73% of patients. Acquired etiologies had a higher rate of Engel I compared to developmental and progressive etiologies (96% vs 46% and 44%, p < 0.001). Nearly half of patients (45%) showed improved cognitive trajectories as opposed to their preoperative ones, whereas in 45% trajectories remained unchanged. Additionally, 5 patients (10%) exhibited new major deficits or accelerated cognitive deterioration after VPH. Surgical complications occurred in 14 patients (29%) after the first VPH; 4 cases were classified as transient, resolving during follow-up without surgical intervention. Nontransient complications included 8 cases of hydrocephalus requiring surgical treatment, 1 shunted subdural hygroma, and 1 case of CSF leakage from the wound. Diabetes insipidus occurred in 6 patients, with all resolving spontaneously. Residual connections were present in 16 patients, primarily in the temporomesial region. Seven patients remained seizure free despite visible residual connections. VPH is a highly effective treatment for drug-resistant hemispheric epilepsy, resulting in durable seizure freedom and often favorable cognitive outcomes. Diabetes insipidus in addition to hydrocephalus is a common complication after VPH. Incomplete disconnection does not necessarily preclude seizure freedom.

Association of air pollutants with psychiatric disorders: a two-sample Mendelian randomization

BackgroundThe link between air pollution and increased risk of psychiatric disorders has been growing in evidence. However, the causal relationship between air pollution and psychiatric disorders remains poorly understood. MethodsSingle-nucleotide polymorphisms associated with air pollutants (including NOx, NO2, PM2.5, PM2.5–10, and PM10) from the UK Biobank were used as instrumental variables. Summary-level data for psychiatric disorders (major depressive disorder, anxiety, bipolar disorder, schizophrenia, post-traumatic stress disorder, attention deficit hyperactivity disorder, autism spectrum disorder, anorexia nervosa, and obsessive-compulsive disorder) were procured from the Psychiatric Genomics Consortium and FinnGen consortium. Two-sample Mendelian randomization (MR) analysis was conducted to analyze the causal associations. ResultsThe MR analysis revealed significant associations between certain air pollutants and specific types of psychiatric disorders. The inverse-variance weighted model of preliminary analysis indicated that genetically predicted NO2 was associated with increased risks of major depressive disorder (odds ratio [OR]: 1.13, 95 % confidence intervals [CI]: 1.00–1.28, P = 0.041), bipolar disorder (OR: 1.26, 95 % CI: 1.00–1.58, P = 0.0497), schizophrenia (OR: 1.57, 95 % CI: 1.23–2.00, P < 0.001), attention deficit hyperactivity disorder (OR: 1.61, 95 % CI: 1.25–2.09, P < 0.001) and autism spectrum disorder (OR: 1.39, 95 % CI: 1.01–1.91, P = 0.044). Genetically predicted PM2.5 showed a positive association with the risk of major depressive disorder (OR: 1.21, 95 % CI: 1.06–1.39, P = 0.006), bipolar disorder (OR: 1.32, 95 % CI: 1.03–1.69, P = 0.030) and attention deficit hyperactivity disorder (OR: 1.57, 95 % CI: 1.16–2.12, P = 0.004). In addition, our results also indicated that NOx (OR: 1.64, 95 % CI: 1.21–2.21, P = 0.0012) and PM10 (OR: 1.70, 95 % CI: 1.23–2.36, P = 0.0014) could increase the risk of attention deficit hyperactivity disorder. ConclusionsThe MR analysis provides evidence for the causality of different air pollutants on specific psychiatric disorders, underscoring the importance of mitigating air pollution to reduce the risk of psychiatric disorders.

Secondary school randomized controlled interventions with a minimum dual approach to health and the links to BMI in pupils: A systematic review and meta-analysis within the project From Science 2 School

Introduction &amp; Purpose Health behavior offers a pivotal domain of health for managing current global crises, including physical inactivity and overweight/obesity (Schroeder, 2007). However, adults have limited capacity for adopting healthy behavior into their lifestyle (Prochaska &amp; Velicer, 1997). Schools offer an ideal setting for implementing health interventions considering the breadth of children that can be reached and the amount of time children spend in school (Tanous et al., 2022). The present study hypothesized that appropriately planned physical activity (PA) intervention for pupils and during compulsory secondary school time results in healthier body weight management. Methods A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, a published protocol (Tanous et al., 2022), and a trial registration was completed on the International Register of Systematic Reviews (PROSPEO: CRD4202347770). The databases searched (12/2021) included PubMed, Education Source, and EMBASE. Only school-based randomized controlled trial interventions on PA and/or diet published in English or German were included. The study population included pupils (10-19 years of age) enrolled in secondary schools and without major nutritional deficit or unstable health condition. The study sample was refined using exclusion criteria: (i) no outcome on body weight, body mass index (BMI), or self-reported, (ii) intervention groups only targeting overweight and/or obese pupils, (iii) interventions outside of regular school hours or implemented beyond the school setting, (iv) total intervention duration less than eight weeks, (v) branches of schools specializing on physical exercise/sports in general, and (vi) no control group. Title/abstract and full-text screening, data appraisal, and summary data extraction were completed by two reviewers. Results A total of 5,945 articles were identified by the search process, including 23 studies and 9,441 pupils (of which 4,787 males and 4,654 females) eligible for the analysis. PA interventions ranged from eight weeks to eight months and included jumping (n = 2), strength exercises (n = 3), cardiovascular endurance (n = 4), or a combination (n = 2). For PA intervention implemented in the secondary level school setting for at least eight weeks duration, a random effect size of -0.12 units (95% CI [-0.26. 0.02]) of BMI (kg/m2) was found with low statistical heterogeneity (I2 = 0%; p = 0.60). Discussion Due to the behavioral constraints of the school setting, children are denied from achieving the minimum level of health protection, which adversely contributes to the poor global health status with a major impact. Previous meta-analyses identified a small PA intervention effect for improving BMI in pupils (-0.02 kg/m2 and -0.05 kg/m2; Guerra et al., 2013; Harris et al., 2009) with considerable heterogeneity (I2 = 77% and 54%, respectively). The findings of the present investigation revealed a more precise effect measure than previous meta-analyses (Guerra et al., 2013; Harris et al., 2009) regarding the exclusive power of the secondary school setting over PA levels and the BMI health improvement possibility for pupils (-0.12 kg/m2). Conclusion PA intervention in secondary schools contributes to limited, yet beneficial body weight management for pupils in the ongoing global health crisis (Schroeder, 2007; Tanous et al., 2022). Considering the lack of formal organization at homes, schools are urged to achieve 60 minutes of PA daily.

Assessment of decision-making autonomy in chronic pain patients: a pilot study

BackgroundPatient decision-making autonomy refers to the patients’ ability to freely exert their own choices and make their own decisions, given sufficient resources and information to do so. In pain medicine, it is accepted that appropriate beneficial management aims to propose an individualized treatment plan shared with the patients, as agents, to help them live as autonomously as possible with their pain. However, are patients in chronic pain centers sufficiently autonomous to participate in the therapeutic decisions that concern them? As this question still remains unanswered, a pilot study was set up to that aim.MethodsOver a 2-month period, first-time patients within a tertiary multidisciplinary pain center underwent a systematic evaluation of their autonomy using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), considered the benchmark tool for measuring a patient’s ability to consent to treatment. Demographic data and pain characteristics of the patients were collected and their respective attending pain physicians were asked to clinically assess their patients’ degree of autonomy. Another physician, who had not participated in the initial patient evaluation, subsequently administered the MacCAT-T questionnaire to the same patients.ResultsTwenty-seven patients were included during the study period (21 women and 6 men), with an average age of 50 years. The average duration of pain was 8 years. Based on their clinical experience, the 4 different pain physicians in charge of these patients considered that out of 25 assessed patients, 22 of them (89%) had full decision-making capacity, with no deficit in autonomy. According to the MacCAT-T results, only 13 of these 25 patients (48%) had no deficit, while 7 (26%) had a major deficit in autonomy. The only patient characteristic that appeared to be related to autonomy was pain type, specifically nociplastic pain. The average time taken to complete the test was 20 min, and patients were very satisfied with the interview.ConclusionResults from the present pilot study suggest that patients suffering from chronic pain do not appear to be entirely autonomous in their decision to consent to the proposed treatment plan according to the MacCAT-T questionnaire, and physicians seem to find it difficult to properly assess this competence in a clinical setting. Further studies with larger samples are needed to better evaluate this concept to improve the complex management of these patients.

Norms for neuropsychological tests in cognitively healthy French oldest old adults.

Normal aging often leads to cognitive decline, and oldest old people, over 80 years old, have a 15% risk of developing neurodegenerative diseases. Therefore, it is important to have appropriate tools to assess cognitive function in old age. The study aimed to provide new norms for neuropsychological tests used to evaluate the cognitive abilities in people aged 80 years and older in France, focusing on the impact of education and gender differences. 107 healthy participants with an average age of 85.2 years, with no neurological history or major cognitive deficits were included. A comprehensive neuropsychological assessment was performed, covering several cognitive functions such as memory, visuospatial abilities, executive functions, attention, processing speed, and praxis. Individuals with lower levels of education performed poorly on some tests and took longer to complete. Gender differences were observed, with women outperforming men in verbal episodic memory, while men showed better performance in visuoconstructive tasks. The participants showed lower performance in verbal episodic memory compared to norms established in previous French studies. In relation to executive functions, participants were slower to perform complex tasks than participants in previous studies. This study provides cognitive norms specifically adapted to the oldest old population, which differ from established norms for younger aging adults. It highlights the importance of including these norms in future clinical and scientific investigations. The findings underscore the importance of education on cognitive abilities and emphasize the need to consider gender differences when assessing cognitive functions in aging populations.

NCCN guideline-concordant cancer care in Sub-Saharan Africa A population-based multi-country study of five cancers.

To assess population-based quality of cancer care in Sub-Saharan Africa and to identify specific gaps and joint opportunities, we assessed concordance of diagnostic and treatment with NCCN harmonized guidelines for leading cancer types in 10 countries. Adult patients with female breast cancer (BC), cervical cancer (CC), colorectal cancer (CRC), Non-Hodgkin lymphoma (NHL) and prostate cancer (PC) were randomly drawn from 11 population-based cancer registries. Guideline concordance of diagnostics and treatment was assessed using clinical records. In a sub-cohort of 906 patients with potentially curable cancer (stage I-III BC, CC, CRC, PC, aggressive NHL (any stage)) and documentation for >1 month after diagnosis, we estimated factors associated with guideline-concordant treatment or minor deviations (GCT). Diagnostic information as per guidelines was complete for 1030 (31.7%)of 3246 patients included. In the sub-cohort with curable cancer, GCT was documented in 374 (41.3%, corresponding to 11.7% of 3246 included in the population-based cohort): aggressive NHL (59.8%/9.1% population-based), BC (54.5%/19.0%), PC (39.0%/6.1%), CRC (33.9%/9.5%), and CC (27.8%/11.6%). GCT was most frequent in Namibia (73.1% of curable cancer subset/32.8% population-based) and lowest in Kampala, Uganda (13.5%/3.1%). GCT was negatively associated with poor ECOG status, locally advanced stage, origin from low HDI countries, and a diagnosis of CRC or CC. Quality of diagnostic workup and treatment showed major deficits, with considerable disparities among countries and cancer types. Improved diagnostic services are necessary to increase the share of curable cancer in SSA. Treatment components within NCCN guidelines synergetic for several cancers should be prioritized.

Present-day stress field, strain rate field and seismicity of the Pannonian region: overview and integrated analysis

We present an overview of recent findings on the seismicity, stress field and strain rate field of the Pannonian region. We furthermore show new inferences for deformation mechanisms and lithospheric rheology via an integrated analysis of the datasets. The N-NW motion of the Dinarides and the opposite, SW motion of the E-and S-Carpathians induce shortening in the western and central Pannonian Basin while leading to regional shearing around the basin's SE boundary. This induces moderate seismic activity related to strike-slip and reverse faulting. Maximum horizontal stress and geodetic shortening directions generally agree, implying that upper crustal stresses and surface deformation correspond to the same forces. 2D rheological models confirm that the shallow upper crust is the only brittle layer in the Pannonian lithosphere, while the brittle-ductile transition zone could be as shallow as 6-9.5 km in the Danube Basin. Comparison of seismic moment rates and moment rate predictions from geodetic strain rates show that deep Pannonian sub-basins accumulate major seismic deficits. This could be explained by dominantly aseismic deformation of the weak upper crust, as supported by a comparison with case studies from different geodynamic environments. Stronger mountainous regions in the study area show no to moderate seismic deficits.

Inclusion of kinesthetics feedback with vision to improve the control of neural activity of the primary motor cortex

In healthy people, the brain controls movement with a high amount of feedback from many modes of perception. Disease or injury compromises these sensory pathways, as well as their neural impulse counterparts, in many people, resulting in major deficits and a lower quality of life. The use of kinesthetics feedback can be used as a therapy method for a variety of neurological diseases like Parkinson's disease (PD) and stroke is gaining popularity. One of these therapeutic possibilities is to use a closed-loop feedback model with mental imagery as the self-regulation support to improve volitional control of malfunctioning or damaged brain networks and nodes. BMIs (Brain–Machine Interfaces) promise to restore function to these people by letting them to control a gadget with their thoughts. The majority of present BMI implementations rely on visual feedback for closed-loop control; But it has been argued that adding more sensory modalities could improve control. The paper shows that kinesthetics feedback may be combined with vision to considerably improve control of a primary motor cortex neural activity (MI). These findings imply that in paralysed individuals with residual kinesthetics feeling, BMI control can be greatly enhanced, and they provide the framework for augmenting cortically controlled BMIs with a variety of surrogate or natural sensory feedback.

Stereotactic Radiosurgery for Intermediate (III) or High (IV-V) Spetzler-Martin Grade Arteriovenous Malformations: International Stereotactic Radiosurgery Society Practice Guideline.

Consensus guidelines do not exist to guide the role of stereotactic radiosurgery (SRS) in the management of patients with Spetzler-Martin Grade III-V arteriovenous malformations (AVMs). We sought to establish SRS practice guidelines for Grade III-V AVMs based on a critical systematic review of the published literature. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant search of Medline, Embase, and Scopus, 1986 to 2023, for publications reporting post-SRS outcomes in ≥10 Grade III-V AVMs with the median follow-up ≥24 months was performed. Primary end points were AVM obliteration and post-SRS hemorrhage. Secondary end points included dosimetric variables, Spetzler-Martin parameters, and neurological outcome. : In total, 2463 abstracts were screened, 196 manuscripts were reviewed, and 9 met the strict inclusion criteria. The overall sample of 1634 AVMs consisted of 1431 Grade III (88%), 186 Grade IV (11%), and 11 Grade V lesions (1%). Total median post-SRS follow-up was 53 months for Grade III and 43 months for Grade IV-V AVMs (ranges, 2-290; 12-262). For Grade III AVMs, the crude obliteration rate was 72%, and among Grade IV-V lesions, the crude obliteration rate was 46%. Post-SRS hemorrhage was observed in 7% of Grade III compared with 17% of Grade IV-V lesions. Major permanent deficits or death from hemorrhage or radiation-induced complications occurred in 86 Grade III (6%) and 22 Grade IV-V AVMs (12%). Most patients with Spetzler-Martin Grade III AVMs have favorable SRS treatment outcomes; however, the obliteration rate for Grade IV-V AVMs is less than 50%. The available studies are heterogenous and lack nuanced, long-term, grade-specific outcomes.

Inter-Ocular Fixation Instability of Amblyopia: Relationship to Visual Acuity, Strabismus, Nystagmus, Stereopsis, Vergence, and Age

PurposeAmblyopia damages visual sensory and ocular motor functions. One manifestation of the damage is abnormal fixational eye movements. Tiny fixation movements are normal; but when these exceed a normal range, the behavior is labeled “fixation instability(FI).” Here we compare FI between normal and amblyopic subjects, and evaluate the relationship between FI and severity of amblyopia, strabismus angle, nystagmus, stereopsis, vergence, and subject age. Design and MethodsFixation Eye Movements were recorded using infra-red video-oculography from 47 controls(15.3±12.2y) and 104 amblyopic subjects(13.3±11.2y) during binocular and monocular viewing. FI and vergence instability were quantified as Bivariate Contour Ellipse Area (BCEA). We also calculated the ratio of FI between the two eyes: right eye/left eye for controls, amblyopic eye/fellow eye for amblyopes. Multiple regression analysis evaluated how FI related to a range of visuo-motor measures. ResultsDuring binocular viewing, the FI of fellow and amblyopic eye, vergence instability and inter-ocular FI ratios were least in anisometropic and most in mixed amblyopia(p<0.05). Each correlated positively with the strabismus angle(p<0.01). During monocular viewing, subjects with deeper amblyopia(p<.01) and larger strabismus angles(p<.05) had higher inter-ocular FI ratios. 27% of anisometropic and >65% of strabismic/mixed amblyopes had nystagmus. Younger age and nystagmus increased FI and vergence instability(p<0.05), but did not affect the Inter-ocular FI ratios(p>0.05). ConclusionsQuantitative recording of perturbed eye movements in children reveal a major functional deficit linked to amblyopia. Imprecise fixation – measured as inter-ocular FI ratios– may be used as a robust marker for amblyopia and strabismus severity.

Prevalence of Risk Factors in Patients with Postprocedural Ischemic Lesions after Coiling of Very Small Intracranial Aneurysms.

Background: Very small intracranial aneurysms, generally considered to be those 3 mm in diameter or smaller, pose particular technical challenges for endovascular surgeons. For this reason, very small aneurysms have been excluded from many relevant studies. The aim of our research was to establish the risk factors for the occurrence of stroke complications after endovascular embolization of ruptured and unruptured small intracranial aneurysms. Methods: During the period of 2009-2023, our team performed endovascular embolizations of intracranial aneurysms in 1567 patients across four different centers within the territory of Serbia and Montenegro. Within the total number of patients mentioned, aneurysms of less than 4 mm were treated 185 times, with 119 ruptured and 66 unruptured. Results: In the group of 119 patients with ruptured small intracranial aneurysms, 19 (16%) patients had ischemia after the endovascular treatment, 6 (5%) patients had minor neurological deficits, while 13 (10.9%) patients had major neurological deficits, of which 6 (5%) patients died. In the group of 66 patients with unruptured small intracranial aneurysms, 7 (10.6%) patients had ischemia after the endovascular treatment, 5 (7.6%) patients had minor neurological deficits, and 2 (3.03%) had major neurological deficits. Multivariate binary logistic regression showed that the risk factors for the occurrence of ischemia were the patient's age, smoking and alcohol consumption. The type of endovascular treatment used also had a statistically significant effect on the development of ischemia. Conclusions: Understanding the influence of possible risk factors for the occurrence of ischemic insult after embolization of small intracranial aneurysms is of great importance. By recognizing them, periprocedural complications can be reduced to a minimum.

A lightweight and privacy preserved federated learning ecosystem for analyzing verbal communication emotions in identical and non-identical databases

The lack of vocal emotional expression is a major deficit in social communication disorders. The current scenario of artificial intelligence focuses on collaborative training of deep learning models without losing data privacy. The primary objective of this paper is to propose a federated learning-based classification model to identify and analyze the emotional capabilities of individuals with vocal emotion deficits. The methodology has developed a collaborative and privacy-preserved approach using federated learning for training the deep learning models. The proposed methodology utilizes Mel-frequency Cepstral Coefficients (MFCC) to preprocess audio recordings. The four datasets (RAVDESS, CREMA, TESS, SAVEE) including emotion-based classified audio recordings were collected from open sources. The collected audio recordings are 3 s each and the total data set has 668376 audio files with happy - 175119 files, sad – 172611 files, angry – 176346 files, and normal - 144300 files. Further, the input audio was pre-processed to generate MFCC features. The study began with extracting features from multiple pre-trained DL models as its base model. Then, the performance of the federated learning (FL) model was tested on independent and identically distributed (IID) and non-IID data. Further, this paper presents a federated deep learning-based multimodal system for verbal communication emotions classification that uses audio datasets to meet data privacy requirements by DL on the FL ecosystem. As per the findings, the federated learning trained model provides nearly similar parametric results in comparison to base model training. For IID data, the model had 99.71 % validation accuracy, precision (99.73 %), recall (99.69 %), and validation loss (0.01). The FL architecture with non-IID data outperformed these measures with validation accuracy (99.97 %), precision (99.97 %), recall (99.97 %), and least loss (0). Hence the acquired results support the utilization of federated learning ecosystem-based trained models with identically and non-identically distributed audio features from emotion identification without losing parametric results. In conclusion, the proposed techniques could be applied to identify verbal emotional deficits in individuals and could support developing emerging technological interventions for their well-being.

QOL-35. ANALYSIS ON THE EVOLUTIONARY PATTERN OF COGNITIVE FUNCTIONS IN CHILDREN ON FOLLOW-UP FOR BRAIN TUMORS

Abstract BACKGROUND Long-term cognitive sequelae of paediatric brain tumors are of increasing interest. The role of histology and surgery remains still unclear. Our study aimed to evaluate children cognitive functioning before and after brain tumors surgery, and at the end of additional treatments. METHODS New diagnoses of paediatric primary brain tumors were prospectively assessed. Neurocognitive evaluations were performed at diagnosis (T0), within 7-10 days from surgery (T1) and 12-18 months after the end of treatments (T2). Language, learning and memory, attention, executive functions, visuo-constructional and sensorimotor skills were evaluated at T0 and T1, Intelligent Quotient (IQ) was explored at T0 and T2. RESULTS Twenty-five patients (M:F=15:10, mean age 10.9±3.4 years) were enrolled between January 2019 and December 2022. In comparison to normal values (&amp;gt;7.0), at baseline patients showed major deficits in narrative memory (6.6±3.7, p&amp;lt;0.001) and visuo-spatial memory (copy design tasks: general 6.8±3.9, p&amp;lt;0.001, specific 6.2±3.3, p&amp;lt;0.001, motor 5.2±3.2, p&amp;lt;0.001). At T1 assessment, significant deficits remained in narrative memory (6.2±3.3, p&amp;lt;0.001) and visual-motor coordination (copy design tasks: specific 5.9±3.0, p&amp;lt;0.001 and motor 4.8±4.3 p&amp;lt;0.001); attention and visual-constructional abilities significantly improved (p=0.04 and p=0.001). On the visual construction test, children with high-grade histology scored lower than the low-grade group (Rey- Osterrieth complex figure-copy 5.1±4.4 vs 11.0±4.3; p=0.019). At T2 evaluation children showed persistent deficits in visuo-spatial processing and a possible decline in IQ scores, with lower scores compared with T0 (93 vs 100, p=0.05). CONCLUSIONS Children with brain tumors may present several neuropsychological impairments at diagnosis, particularly those with high-grade diseases. Surgery may have a positive effect on the recovery of some cognitive functions. However, cognitive decline may worsen over time. Baseline and periodic neurocognitive evaluations should be encouraged to identify functional difficulties and to develop a tailored treatment approach for the patient.

A longitudinal, palliative care educational pilot in hematology-oncology fellowship training.

9007 Background: Despite national guidelines advocating that patients (pts) with advanced cancer receive dedicated palliative care (PC) services, many pts lack access to specialty PC, due to PC workforce shortage. Training hematology-oncologists (HOs) to provide primary PC could close this gap and ensure basic PC needs of pts are met. While HO fellowships require demonstration of competence in PC skills, studies have shown major deficits in PC knowledge, educational experiences and confidence. We designed a longitudinal, integrated, PC continuity rotation for HO fellows. We report feasibility, acceptability, perceived value, and impact on knowledge and practice of this novel educational model. Methods: Over 6 months, HO fellows identified patients with PC needs from their HO continuity practice and referred them to PC clinic. Fellows then saw those pts in PC clinic with the PC attending and in HO clinic with the HO attending, as well as during hospitalizations. Pt visits and HO fellow participation were tracked for feasibility. Fellows were surveyed before and after the rotation on skill confidence and knowledge, which were compared using generalized linear models for unmatched data. After the rotation, they were surveyed on acceptability and teaching quality; they also participated in a semi-structured interview assessing educational value. Fellows electronically gave informed consent for participation; the project was approved by the institutional IRB. Results: From 2018-2023, 19 fellows from 3 HO fellowship classes participated. All 19 referred 2-4 of their continuity oncology pts to the PC team and then followed these pts in both clinics longitudinally over 6 months. A total of 51 pts (#fellows-#pts: 9-2 pts; 7-3 pts; 3-4 pts) had a total of 132 PC visits. Fellows participated in 125/132 PC visits (95%); the majority were outpatient (94/132; 71%). From pre to post intervention, there was an improvement in fellows’ PC knowledge (mean 6.44/10 to 7.92, p&lt;0.01) and overall feeling of preparedness to provide PC (mean 6.33/10 to 7.75, p&lt;0.01). Ratings of skill confidence improved in 14 of 26 items (p&lt;0.05), including titration of opioids, managing pain in pts with substance use disorder, recognizing when to consider methadone, and working with an interdisciplinary team. Of 17 fellows rating acceptability, 16 (94%) rated the rotation as valuable or extremely valuable, 15 (88%) agreed or strongly agreed the rotation structure was effective, and 17 (100%) agreed or strongly agreed the rotation both changed their clinical practice and helped them feel more engaged in working with their sickest pts. Conclusions: Our pilot study of a novel, longitudinal, integrated, PC continuity rotation for HO fellows was highly feasible and acceptable. The rotation changed clinical practice and improved fellows’ PC knowledge and skill confidence. This could serve as a model for integrating PC education into HO fellowships nationally.

Self-Management Programs and the Pursuit of Behavior Change.

A self-management intervention is a personalized approach to individuals aiming to engage individuals in a behavior change to develop skills to live better with their condition. Self-management involves an iterative process between participants and providers in which goals are formulated and feedback is given. All respiratory societies advocate self-management as part of chronic care because it may improve quality of life and health-care utilization. Self-management is an integral part of pulmonary rehabilitation. Self-management interventions usually involve education and exercise prescription, and that is an asset of current programs; however, recent reports indicate that effective strategies for motivation and a behavior change focus are often missed. A recent systematic review on self-management urges the need for a specific aspect and characteristic of self-management interventions: iterative interactions between participants and health-care professionals competent in using behavior change practices to elicit participants' motivation, confidence, and competence to develop skills to better manage their disease. A recent review of self-care intervention in chronic disease states that the major deficits found in self-care interventions included a lack of attention and/or innovation to the psychological consequences of chronic illness, technology, and behavior change techniques to help patients manage symptoms. There is a need for exploration of mechanisms to explain the relationships between both anxiety and depression, and adherence to treatment in COPD. The latter is particularly appropriate for pulmonary rehabilitation, for which greater adherence is needed. This report aims to introduce basic aspects of behavior change and a proposed roadmap to introduce behavior change into pulmonary rehabilitation and chronic care programs.

Sociodemographic patterns of spinal tuberculosis patients from a tertiary care teaching hospital: A 5-year cross-sectional study.

The distribution of spinal tuberculosis (STB) differs due to variations in lifestyles, socio-economic conditions, geographical locations, available medical services, and other factors. In the literature, very few studies have been done on demographic profile and morphological distribution of tuberculosis (TB) spine. We conducted this study to identify the disease distribution and various parameters affecting the disease in our area which caters to populations from both plains and hills. This was a cross-sectional study using 5-year retrospective data retrieved from medical records, Department of Orthopaedics of a tertiary care teaching hospital, from April 2015 to October 2020. The patient distribution was studied according to the different variables. A total of 286 patients were enrolled in the study. Females amounted to 54.96% (n = 159) of the total and 46.1% (n = 127) were males. The mean age of the demographic group was 36.9 years (2.5-80 years) (±SD = 17.63). The majority (46.5%) of the patients were young adults in the age group (21-40 years). The majority of deficits were seen in the dorsal spine (n = 27) followed by multifocal contiguous lesions (n = 22). Among the patients having single-segment disease, 33.9% (n = 61) involved the lumbar spine and 28.7% (n = 52) involved the dorsolumbar spine. Multifocal Potts disease amounted to 36.25% (n = 105) of the total patients. Female preponderance was observed in our study. Involvement of the lumbar spine was the most common form involving single-segment disease followed by dorsolumbar, dorsal, and cervical spine. The multifocal contiguous type of affection of STB was found to be the most common type of STB.

Expanding the reach of the trans-middle cerebellar peduncle approach: pontine cavernous malformations, tissue transgression beyond the safe entry zone, and the invisible triangle.

In the authors' microsurgical experience, the trans-middle cerebellar peduncle (MCP) approach to the lateral and central pons has been the most common approach to brainstem cavernous malformations (BSCMs). This approach through a well-tolerated safe entry zone (SEZ) allows a wide vertical or posterior trajectory, reaching pontine lesions extending into the midbrain, medulla, and pontine tegmentum. Better understanding of the relationships among lesion location, surgical trajectory, and long-term clinical outcomes could determine areas of safe passage. A single-surgeon cohort study of all primary trans-MCP BSCM resections was conducted from July 1, 2017, to June 30, 2021. Preoperative and postoperative MR images were independently reviewed by 3 investigators blinded to the intervention, using a standardized rubric to define BSCM regions of interest (ROIs) involved with a lesion or microsurgical tract. Statistical testing, including the chi-square test with the Bonferroni correction, logistic regression, and structural equation modeling, was performed to analyze relationships between ROIs and clinical outcomes. Thirty-one patients underwent primary trans-MCP BSCM resection during the study period. The median age was 50 years (IQR 24-49 years); 19 (61%) patients were female, and 12 (39%) were male. Seven (23%) patients had familial cavernous malformation syndromes. The median follow-up was 9 months (range 6-37 months). At the last follow-up, composite neurological outcomes were favorable: 22 (71%) patients had 0 (n = 12, 39%) or 1 (n = 10, 32%) major persistent deficit, 5 patients (16%) had 2 deficits, 2 (7%) had 3 deficits, and 1 patient each (3%) had 4 or 6 deficits. Unfavorable composite outcomes were significantly associated with lesions (OR 7.14, p = 0.04) or surgical tracts (OR 12.18, p < 0.001) extending from the superior cerebellar peduncle (SCP) into the contralateral medial midbrain. The ipsilateral dorsal pons was the most frequently implicated ROI involving a surgical tract and the development of new postoperative deficits. This region involved the rhomboid pontine territory and transgression of the pontine tegmentum (OR 7.53, p < 0.001). Structural equation modeling supported medial midbrain and pontine tegmentum transgression as the primary drivers of morbidity. Trans-MCP resection is a safe and effective treatment for BSCMs, including lesions with marked superior or inferior ipsilateral extension. Two trajectories are associated with increased neurological risk: first, a superomedial trajectory to lesions extending into the midbrain that transgresses the SCP, its decussation, or both; and second, a posteromedial trajectory to lesions extending into the pontine tegmentum. The corticospinal tract, SCP, and pontine tegmentum form an invisible triangle within the pontine white matter tolerant of transgression. When the surgeon works within this triangle, most deep pontine BSCMs, including large lesions, those with contralateral or posterior extension, and others extending into the midbrain and medulla, can be resected safely with the trans-MCP approach.

Spinal tumor embolization with Onyx: A systematic review and meta-analysis.

Onyx embolization has emerged as a promising technique for spinal tumor embolization due to its high devascularization rate and low incidence of complications. Evaluate the safety and efficacy of Onyx embolization in spinal tumor procedures. Following the PRISMA guidelines, we conducted a systematic review and meta-analysis. To be included, the articles had to report specific outcomes of Onyx embolization for spinal tumors (complications, mortality, blood loss, tumor devascularization, or reduction in tumor blush). We selected 11 out of 2941 articles, encompassing 127 patients. Among them, no major complications or persistent neurological deficits were reported, and no deaths occurred as a result of the embolization procedure. Of the 63 patients with available data, two complications were observed: one infarct leading to transient neurological deficit and one clinically silent vessel perforation related to the microcatheter. Thus, the complication rate was 1% (95% confidence interval (CI): 0% to 6%). Blood loss during surgery ranged from 100 to 1500 mL (four studies). Complete tumor blush reduction was achieved in 52% of the cases (95% CI: 16% to 88%) across 32 patients. Three studies reported a median percentage of tumor devascularization of 91% (86.1% to 97.5%). Onyx embolization for spinal tumor procedures appears to be a safe technique, as evidenced by the absence of major complications or deaths. However, the determination of its efficacy remains challenging due to limited data availability and substantial heterogeneity across studies. These findings highlight the need for future research to address this knowledge gap and further validate our results.

Major adverse foot events and functional mobility deficits associated with diabetic neuropathy and nephropathy.

The purpose is to determine the risk ratios (RR) for both major adverse foot events (MAFEs) and the presence of moderate and severe functional mobility deficits in participants with diabetic peripheral neuropathy across the stages of chronic kidney disease (CKD). We studied 284 participants with diabetes mellitus, peripheral neuropathy, and CKD. MAFEs including foot fracture, ulcerations, Charcot neuropathic arthropathy (CN), osteomyelitis, and minor foot amputations were collected from foot x-ray reports in the medical records of 152 participants; functional mobility deficits were assessed in 132 participants using the modified physical performance test (mPPT). Moderate mobility deficit was categorized as mPPT scores 22-29 and severe mobility deficit as < 22. Unadjusted and adjusted (age, body weight, race, HbA1c) RR were calculated across each stage of CKD, with stage 1 CKD used as the reference group. The RR for neuropathic foot fracture, CN, and diabetic foot ulceration remained consistent across CKD stages. The RR of minor amputation is greater in CKD stages 4 and 5. The RR of moderate or severe mobility deficit is greater in CKD stages 3 and 5 and in CKD stages 3, 4, and 5, respectively. An inverse association was observed between MAFE prevalence and mPPT scores across CKD stages. Major adverse foot events and functional mobility deficits are prevalent in individuals with DPN and diabetic kidney disease. The risks for minor foot amputation and functional mobility deficits increase as early as stage 3 CKD and increase further in stages 4 and 5.