Presurgical Testing Research Articles

A - 147 Patient-Centric Considerations for Selecting the Language of Procedure Administration in Candidates for Epilepsy Surgery: Implications for Data Interpretation, Prognostication and Outcomes

Abstract Objective Selecting the language of pre-surgical neuropsychological testing (NPT), intracarotid amobarbital procedure, and intra/extra functional language mapping (ESM) in bi−/multi-lingual patients is a high-stakes neuropsychological decision point. Though a patient’s self-selection of language is an integral consideration, both patient and provider must fully understand the potential implications of language selection on a patient’s data interpretation and overall case conceptualization. Method A 26-year-old, right-handed, bilingual (L1 = Mandarin-, L2 = English-speaking) female received pre-operative NPT, Wada test, and ESM to guide resective surgery targeting medically-refractory epilepsy involving the right superior temporal gyrus (STG) and mesial (MTL) temporal lobe. All procedures were conducted in English at the patient’s request with alternate forms of verbally-mediated NPT administered in Mandarin. Results Confrontation naming and verbal fluencies were impaired in both English and Mandarin. Wada testing administered in English revealed bilateral language and greater left hemisphere memory support. Following considerable psychoeducation regarding possible functional language loss in Mandarin post-operatively, the patient agreed to ESM in L1 with auditory and picture naming disruption after right STG stimulation. Conclusion Despite strong English-language fluency, assessment in Mandarin was of critical importance, as eloquent cortices essential for tonal language production may have been resected if mapping procedures were completed in English-only, as requested. Balancing factors informed by functional and structural neuroanatomy, patient worldview, and cross-cultural neuropsychology requires a tailored, patient-centric approach to case conceptualization.

Low-invasive somatic oncogenes and lymph node metastasis in pediatric papillary thyroid cancer: implications for prophylactic central neck dissection.

The American Thyroid Association (ATA) Pediatric Guidelines recommend selective, prophylactic central neck dissection (pCND) for patients with papillary thyroid carcinoma (PTC) based on tumor focality, tumor size, and the surgeon's experience. With the expansion of pre-surgical somatic oncogene testing and continued controversy over the benefits of pCND, oncogenic alteration data may provide an opportunity to stratify pCND. This study compared lymph node (LN) involvement in pediatric patients with PTC between tumors with low- and high-invasive-associated alterations to explore the potential utility of preoperative oncogenic alterations in the stratification of pCND. This is retrospective cohort study of pediatric patients who underwent somatic oncogene testing post thyroidectomy for PTC between July 2003 and July 2022. Of 192 eligible PTC patients with postoperative somatic oncogene data, 19 tumors harbored somatic alterations associated with low-invasive disease (19/192, 10%), and 128 tumors harbored a BRAFV600E alteration (45/192, 23%) or an oncogenic fusion (83/192, 43%). Tumors with low-invasive alterations were less likely to present malignant preoperative cytology (2/18, 11%) than those with high-invasive alterations (97/124, 78%; P < 0.001). Twelve patients with low-invasive alterations had LNs dissected from the central neck (12/19, 63%) compared to 127 patients (127/128, 99%) with high-invasive alterations. LN metastasis was identified in two patients with low-invasive alterations (2/19, 11%) compared to 107 patients with high-invasive alterations (107/128, 84%; P < 0.001). Pediatric patients with low-invasive somatic oncogenic alterations are at low risk for metastasis to central neck LNs. Our findings suggest that preoperative knowledge of somatic oncogene alterations provides objective data to stratify pediatric patients who may not benefit from pCND.

Diagnosis and management of urinary bladder paragangliomas: A Sino-American-European retrospective observational study.

Paragangliomas of the urinary bladder (UBPGLs) are rare neuroendocrine tumours and pose a diagnostic and surgical challenge. It remains unclear what factors contribute to a timely presurgical diagnosis. The purpose of this study is to identify factors contributing to missing the diagnosis of UBPGLs before surgery. A total of 73 patients from 11 centres in China, and 51 patients from 6 centres in Europe and 1 center in the United States were included. Clinical, surgical and genetic data were collected and compared in patients diagnosed before versus after surgery. Logistic regression analysis was used to identify clinical factors associated with initiation of presurgical biochemical testing. Among all patients, only 47.6% were diagnosed before surgery. These patients were younger (34.0 vs. 54.0 years, p < .001), had larger tumours (2.9 vs. 1.8 cm, p < .001), and more had a SDHB pathogenic variant (54.7% vs. 11.9%, p < .001) than those diagnosed after surgery. Patients with presurgical diagnosis presented with more micturition spells (39.7% vs. 15.9%, p = .003), hypertension (50.0% vs. 31.7%, p = .041) and catecholamine-related symptoms (37.9% vs. 17.5%, p = .012). Multivariable logistic analysis revealed that presence of younger age (<35 years, odds ratio [OR] = 6.47, p = .013), micturition spells (OR = 6.79, p = .007), hypertension (OR = 3.98, p = .011), and sweating (OR = 41.72, p = .013) increased the probability of initiating presurgical biochemical testing. Most patients with UBPGL are diagnosed after surgery. Young age, hypertension, micturition spells and sweating are clues in assisting to initiate early biochemical testing and thus may establish a timely presurgical diagnosis.

Navigating the Usher Syndrome Genetic Landscape: An Evaluation of the Associations between Specific Genes and Quality Categories of Cochlear Implant Outcomes.

Usher syndrome (US) is a clinically and genetically heterogeneous disorder that involves three main features: sensorineural hearing loss, retinitis pigmentosa (RP), and vestibular impairment. With a prevalence of 4-17/100,000, it is the most common cause of deaf-blindness worldwide. Genetic research has provided crucial insights into the complexity of US. Among nine confirmed causative genes, MYO7A and USH2A are major players in US types 1 and 2, respectively, whereas CRLN1 is the sole confirmed gene associated with type 3. Variants in these genes also contribute to isolated forms of hearing loss and RP, indicating intersecting molecular pathways. While hearing loss can be adequately managed with hearing aids or cochlear implants (CIs), approved RP treatment modalities are lacking. Gene replacement and editing, antisense oligonucleotides, and small-molecule drugs hold promise for halting RP progression and restoring vision, enhancing patients' quality of life. Massively parallel sequencing has identified gene variants (e.g., in PCDH15) that influence CI results. Accordingly, preoperative genetic examination appears valuable for predicting CI success. To explore genetic mutations in CI recipients and establish correlations between implant outcomes and involved genes, we comprehensively reviewed the literature to gather data covering a broad spectrum of CI outcomes across all known US-causative genes. Implant outcomes were categorized as excellent or very good, good, poor or fair, and very poor. Our review of 95 cochlear-implant patients with US, along with their CI outcomes, revealed the importance of presurgical genetic testing to elucidate potential challenges and provide tailored counseling to improve auditory outcomes. The multifaceted nature of US demands a comprehensive understanding and innovative interventions. Genetic insights drive therapeutic advancements, offering potential remedies for the retinal component of US. The synergy between genetics and therapeutics holds promise for individuals with US and may enhance their sensory experiences through customized interventions.

Cardiorespiratory fitness and morbidity and mortality in patients with non-small cell lung cancer: a prospective study with propensity score weighting

Introduction This study aimed to investigate the association between cardiorespiratory fitness (CRF) and perioperative morbidity and long-term mortality in operable patients with early-stage non-small cell lung cancer (NSCLC). Patients and Methods This prospective study included consecutive patients with early-stage NSCLC who underwent presurgical cardiopulmonary exercise testing between November 2014 and December 2019 (registration number: ChiCTR2100048120). Logistic and Cox proportional hazards regression were applied to evaluate the correlation between CRF and perioperative complications and long-term mortality, respectively. Propensity score overlap weighting was used to adjust for the covariates. We performed sensitivity analyses to determine the stability of our results. Results A total of 895 patients were followed for a median of 40 months [interquartile range 25]. The median age of the patients was 59 years [range 26–83], and 62.5% were male. During the study period, 156 perioperative complications and 146 deaths were observed. Low CRF was associated with a higher risk of death (62.9 versus 33.6 per 1000 person-years; weighted incidence rate difference, 29.34 [95% CI, 0.32 to 58.36] per 1000 person-years) and perioperative morbidity (241.6 versus 141.9 per 1000 surgeries; weighted incidence rate difference, 99.72 [95% CI, 34.75 to 164.70] per 1000 surgeries). A CRF of ≤ 20 ml/kg/min was significantly associated with a high risk of long-term mortality (weighted hazard ratio, 1.98 [95% CI, 1.31 to 2.98], p < 0.001) and perioperative morbidity (weighted odds ratio, 1.93 [1.28 to 2.90], p = 0.002) compared to higher CRF. Conclusion The study found that low CRF is significantly associated with increased perioperative morbidity and long-term mortality in operable patients with early-stage NSCLC.

32 Prediction of Seizure Outcome with Presurgical IAT, MRI, and PET in Patients with Temporal Lobe Epilepsy Undergoing Surgery

Objective:Anterior temporal lobectomy is a common surgical approach for medication-resistant temporal lobe epilepsy (TLE). Prior studies have shown inconsistent findings regarding the utility of presurgical intracarotid sodium amobarbital testing (IAT; also known as Wada test) and neuroimaging in predicting postoperative seizure control. In the present study, we evaluated the predictive utility of IAT, as well as structural magnetic resonance imaging (MRI) and positron emission tomography (PET), on long-term (3-years) seizure outcome following surgery for TLE.Participants and Methods:Patients consisted of 107 adults (mean age=38.6, SD=12.2; mean education=13.3 years, SD=2.0; female=47.7%; White=100%) with TLE (mean epilepsy duration =23.0 years, SD=15.7; left TLE surgery=50.5%). We examined whether demographic, clinical (side of resection, resection type [selective vs. non-selective], hemisphere of language dominance, epilepsy duration), and presurgical studies (normal vs. abnormal MRI, normal vs. abnormal PET, correctly lateralizing vs. incorrectly lateralizing IAT) were associated with absolute (cross-sectional) seizure outcome (i.e., freedom vs. recurrence) with a series of chi-squared and t-tests. Additionally, we determined whether presurgical evaluations predicted time to seizure recurrence (longitudinal outcome) over a three-year period with univariate Cox regression models, and we compared survival curves with Mantel-Cox (log rank) tests.Results:Demographic and clinical variables (including type [selective vs. whole lobectomy] and side of resection) were not associated with seizure outcome. No associations were found among the presurgical variables. Presurgical MRI was not associated with cross-sectional (OR=1.5, p=.557, 95% CI=0.4-5.7) or longitudinal (HR=1.2, p=.641, 95% CI=0.4-3.9) seizure outcome. Normal PET scan (OR= 4.8, p=.045, 95% CI=1.0-24.3) and IAT incorrectly lateralizing to seizure focus (OR=3.9, p=.018, 95% CI=1.2-12.9) were associated with higher odds of seizure recurrence. Furthermore, normal PET scan (HR=3.6, p=.028, 95% CI =1.0-13.5) and incorrectly lateralized IAT (HR= 2.8, p=.012, 95% CI=1.2-7.0) were presurgical predictors of earlier seizure recurrence within three years of TLE surgery. Log rank tests indicated that survival functions were significantly different between patients with normal vs. abnormal PET and incorrectly vs. correctly lateralizing IAT such that these had seizure relapse five and seven months earlier on average (respectively).Conclusions:Presurgical normal PET scan and incorrectly lateralizing IAT were associated with increased risk of post-surgical seizure recurrence and shorter time-to-seizure relapse.

Preoperative thalamus volume is not associated with preoperative cognitive impairment (preCI) or postoperative cognitive dysfunction (POCD)

A growing body of literature suggests the important role of the thalamus in cognition and neurodegenerative diseases. This study aims to elucidate whether the preoperative thalamic volume is associated with preoperative cognitive impairment (preCI) and whether it is predictive for postoperative cognitive dysfunction at 3 months (POCD). We enrolled 301 patients aged 65 or older and without signs of dementia who were undergoing elective surgery. Magnetic resonance imaging was conducted prior to surgery. Freesurfer (version 5.3.) was used to automatically segment the thalamus volume. A neuropsychological test battery was administered before surgery and at a 3 month follow-up. It included the computerized tests Paired Associate Learning (PAL), Verbal Recognition Memory (VRM), Spatial Span Length (SSP), Simple Reaction Time (SRT), the pen-and-paper Trail-Making-Test (TMT) and the manual Grooved Pegboard Test (GPT). Using a reliable change index, preCI and POCD were defined as total Z-score > 1.96 (sum score over all tests) and/or Z-scores > 1.96 in ≥ 2 individual cognitive test parameters. For statistical analyses, multivariable logistic regression models were applied. Age, sex and intracranial volume were covariates in the models. Of 301 patients who received a presurgical neuropsychological testing and MRI, 34 (11.3%) had preCI. 89 patients (29.5%) were lost to follow-up. The remaining 212 patients received a follow-up cognitive test after 3 months, of whom 25 (8.3%) presented with POCD. Independently of age, sex and intracranial volume, neither preCI (OR per cm3 increment 0.81 [95% CI 0.60–1.07] p = 0.14) nor POCD (OR 1.02 per cm3 increment [95% CI 0.75–1.40] p = 0.87) were statistically significantly associated with patients’ preoperative thalamus volume. In this cohort we could not show an association of presurgical thalamus volume with preCI or POCD.Clinical Trial Number: NCT02265263 (https://clinicaltrials.gov/ct2/show/results/NCT02265263).

A115 Role of Pre-Surgical Metabolic Testing for Procedure selection in Bariatric Surgery Principal Investigator

A115 Role of Pre-Surgical Metabolic Testing for Procedure selection in Bariatric Surgery Principal Investigator

Outcome after laser interstitial thermal therapy (LITT) in patients with drug-resistant epilepsy (P2-1.002)

<h3>Objective:</h3> To investigate the outcome of seizure freedom among patients with DRE who underwent LITT for temporal lobe epilepsy (TLE) and extratemporal lobe epilepsy (ETLE) and identify factors contributing to seizure recurrence after LITT. <h3>Background:</h3> Surgical resections offer the highest chance for seizure freedom for patients with drug-resistant epilepsy (DRE); however, over the last few years, there has been increased interest in exploring more minimally invasive surgical techniques, such as laser interstitial thermal therapy (LITT). <h3>Design/Methods:</h3> This retrospective chart review included patients who underwent LITT from 2015–2021. We collected data on demographics, clinical history, presurgical testing, postoperative complications, and seizure freedom outcomes at various time points. We conducted t-tests and Fisher’s exact tests to compare the percentages of seizure freedom for each factor of interest and a linear regression to determine whether these factors are strong predictors of seizure recurrence. <h3>Results:</h3> 19 out of 29 patients (65.5%) were seizure free one year after LITT and 13/29 (44%) were seizure free at the last visit (mean FU duration = 49.5 months). Seizure freedom was 50% (12/24) among the TLE group and 20% (1/5) among the ETLE group at the last visit (p=0.343). Five patients (17%) had acute post-operative complications, which were reversible. Two patients (7%) reported memory and comprehension impairments. Gender, family history of epilepsy, handedness, etiology, and epilepsy duration were not significantly associated with seizure recurrence. Six patients underwent a re-operation, with five anterior temporal lobectomies and one additional ablation. Three of the ATL patients were seizure free after the operation, but the additional ablation did not result in seizure freedom. <h3>Conclusions:</h3> LITT can potentially offer seizure freedom to carefully selected patients with DRE. Our study showed the TLE group had higher proportions of patients with seizure freedom in comparison to the ETLE group, but it was not statistically significant given the small sample size. <b>Disclosure:</b> Ms. In has nothing to disclose. Dr. El Refaey has nothing to disclose. The institution of Dr. Castellano has received research support from NIH. Mark Richardson has received personal compensation in the range of $500-$4,999 for serving as a Consultant for SetPoint Medical. Mark Richardson has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Neurocrine. Mark Richardson has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biogen. Mark Richardson has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for AskBio. Mark Richardson has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Voyager Therapeutics. Dr. Bagic has nothing to disclose. Dr. Barot has nothing to disclose.

PD36-05 ASSESSMENT OF CIRCULATING TUMOR DNA STATUS AS A PROGNOSTIC MARKER FOR RECURRENCE DETECTION IN PATIENTS WITH MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyCME1 Apr 2023PD36-05 ASSESSMENT OF CIRCULATING TUMOR DNA STATUS AS A PROGNOSTIC MARKER FOR RECURRENCE DETECTION IN PATIENTS WITH MUSCLE INVASIVE BLADDER CANCER Shivaram Cumarasamy, George Laliotis, Elshaddai White, Jordan Rich, Punashi Dutta, Shruti Sharma, Mark Calhoun, Adam Elnaggar, Minetta Liu, Kyrollis Attalla, Reza Mehrazin, Peter Wiklund, and John Sfakianos Shivaram CumarasamyShivaram Cumarasamy More articles by this author , George LaliotisGeorge Laliotis More articles by this author , Elshaddai WhiteElshaddai White More articles by this author , Jordan RichJordan Rich More articles by this author , Punashi DuttaPunashi Dutta More articles by this author , Shruti SharmaShruti Sharma More articles by this author , Mark CalhounMark Calhoun More articles by this author , Adam ElnaggarAdam Elnaggar More articles by this author , Minetta LiuMinetta Liu More articles by this author , Kyrollis AttallaKyrollis Attalla More articles by this author , Reza MehrazinReza Mehrazin More articles by this author , Peter WiklundPeter Wiklund More articles by this author , and John SfakianosJohn Sfakianos More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003334.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Though radical cystectomy (RC) is the gold standard treatment for patients with muscle invasive bladder cancer (MIBC), ∼50% of patients recur. Here, we aimed to elucidate the ability of circulating tumor DNA (ctDNA) as a prognostic biomarker to predict disease recurrence in patients who underwent RC. METHODS: ctDNA analysis was retrospectively performed in a cohort of 49 MIBC patients with a median age of 70 years (range: 46-88 years) and 81.63% (40/49) male. In this cohort, patients were subjected to RC alone (RC group, N=38) or neoadjuvant chemotherapy (NAC) followed by RC (NAC+RC group, N=11). A total of 62 blood samples were collected from 11/18/21 to 09/21/22 for a median follow-up of 8.01 months (range: 2.23 - 63.76 months). ctDNA was analyzed prior to (N=26) and after RC (N=36) using a personalized, tumor-informed ctDNA assay (SignateraTM, mPCR - NGS assay); its association with clinical outcomes was assessed. RESULTS: In this cohort, presurgical (baseline) mean MTM levels were significantly associated with advanced stage (III/IV) compared to early stage (I/II) disease, p=0.033 (Figure 1A). Among 26 and 36 patients with baseline and post-RC blood samples available, ctDNA detection rate was 34.6% (9/26) and 22.2% (8/36), respectively. ctDNA-positive patients were only observed in the RC group at both baseline (N=9) and post-RC (N=8). Clinical recurrence was observed in 22.2% (2/9) and 25% (2/8) of patients at the baseline and post-RC time points, respectively. Conversely, no recurrences were seen among the RC group who were ctDNA negative at both time points (NPV: 100%). Our data suggest that patients with ctDNA-positivity had a higher probability of recurrence (chi-square, p<0.001) (Figure 1B). On analyzing the association of ctDNA status post-RC with the survival benefit, ctDNA-positivity was associated with poorer recurrence free survival (RFS) (HR=13.13; 95%CI: 0.73 - 234, p=0.08) (Figure 1C). CONCLUSIONS: We report early results of presurgical (baseline) and post-RC ctDNA testing in patients with MIBC. ctDNA-negativity at both time points correlated with absence of disease recurrence. Further clinical evaluation with a longer follow-up is warranted to fully validate the role of baseline ctDNA in upfront clinical disease management. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e981 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shivaram Cumarasamy More articles by this author George Laliotis More articles by this author Elshaddai White More articles by this author Jordan Rich More articles by this author Punashi Dutta More articles by this author Shruti Sharma More articles by this author Mark Calhoun More articles by this author Adam Elnaggar More articles by this author Minetta Liu More articles by this author Kyrollis Attalla More articles by this author Reza Mehrazin More articles by this author Peter Wiklund More articles by this author John Sfakianos More articles by this author Expand All Advertisement PDF downloadLoading ...

Nil per os duration and anxiety: A single center cross-sectional study

IntroductionPreoperative fasting prior to general anesthesia or sedation is utilized to reduce the risk of aspiration and the severity of the pulmonary sequelae should aspiration occur. Consensus fasting guidelines are established, however, existing data indicates that patients continue to fast significantly longer than is recommended prior to surgery. The aim of this study was to understand the true preoperative solid and clear liquid fasting durations and its concomitant effect on somatic symptoms in patients undergoing surgery at a large tertiary care medical center. MethodsAmbulatory patients scheduled for elective procedures were enrolled during pre-surgical testing or on the day of surgery. Standard ASA fasting guideline base instructions were given to patients during their in-person pre-surgical testing visit. Subject participation required a brief in-person questionnaire prior to surgery. Patients were divided into morning, afternoon or evening groups and a one-way ANOVA was performed to compare mean fasting times. ResultsThree-hundred-and-ninety-nine patients completed the survey. 95% (n = 379) of patients indicated that fasting instructions were clear prior to surgery; 4.76% (n = 19) recalled being told they could drink clear liquids up to two hours before surgery. Average fasting time for solids and clear liquids was 16.13 and 14.95 h. Mean solid fasting durations were 11.55, 15.03, and 17.73 h (p < 0.0001) and clear liquids fast durations were 10.00, 14.05, 16.80 h (p < 0.0001) for morning, afternoon and evening cases, respectively. Female patients and those reporting hunger and thirst preoperatively were more likely to report moderate to severe anxiety preoperatively (p = 0.007, p = 0.0002, p < 0.0001). ConclusionDespite universal guidelines advocating for decreased fasting practices, nil per os times remain significantly prolonged. Preoperative anxiety is associated with prolonged solid and liquid fasting duration.

Presurgical Language Mapping: What Are We Testing?

Gliomas are brain tumors infiltrating healthy cortical and subcortical areas that may host cognitive functions, such as language. If these areas are damaged during surgery, the patient might develop word retrieval or articulation problems. For this reason, many glioma patients are operated on awake, while their language functions are tested. For this practice, quite simple tests are used, for example, picture naming. This paper describes the process and timeline of picture naming (noun retrieval) and shows the timeline and localization of the distinguished stages. This is relevant information for presurgical language testing with navigated Magnetic Stimulation (nTMS). This novel technique allows us to identify cortical involved in the language production process and, thus, guides the neurosurgeon in how to approach and remove the tumor. We argue that not only nouns, but also verbs should be tested, since sentences are built around verbs, and sentences are what we use in daily life. This approach's relevance is illustrated by two case studies of glioma patients.

Could pre-surgical genomic testing inform neoadjuvant chemotherapy decision making in breast cancer and increase patient individualised surgical options?

Could pre-surgical genomic testing inform neoadjuvant chemotherapy decision making in breast cancer and increase patient individualised surgical options?

Clinical Issues-January 2023.

Janus kinase inhibitor therapy and venous thromboembolism risk factors Key words: Janus kinase (JAK) inhibitor, tofacitinib, inflammatory bowel disease (IBD), ulcerative colitis, extended-duration prophylaxis. Identifying validated venous thromboembolism risk assessment tools Key words: venous thromboembolism (VTE) protocol, Caprini risk assessment model (RAM), risk identification, clinical workflow, bleeding risk. Timing of the preoperative venous thromboembolism risk assessment Key words: Caprini risk assessment model (RAM), venous thromboembolism (VTE) risk, patient assessment, presurgical testing visit, family history. Communicating venous thromboembolism and bleeding risk after surgery Key words: venous thromboembolism (VTE) risk, bleeding risk, hand over, postanesthesia care unit RN, intraoperative events.

Epilepsy center characteristics and geographic region influence presurgical testing in the United States.

Persons with drug-resistant epilepsy may benefit from epilepsy surgery and should undergo presurgical testing to determine potential candidacy and appropriate intervention. Institutional expertise can influence use and availability of evaluations and epilepsy surgery candidacy. This census survey study aims to examine the influence of geographic region and other center characteristics on presurgical testing for medically intractable epilepsy. We analyzed annual report and supplemental survey data reported in 2020 from 206 adult epilepsy center directors and 136 pediatric epilepsy center directors in the United States. Test utilization data were compiled with annual center volumes, available resources, and US Census regional data. We used Wilcoxon rank-sum, Kruskal-Wallis, and chi-squared tests for univariate analysis of procedure utilization. Multivariable modeling was also performed to assign odds ratios (ORs) of significant variables. The response rate was 100% with individual element missingness < 11% across 342 observations undergoing univariate analysis. A total of 278 complete observations were included in the multivariable models, and significant regional differences were present. For instance, compared to centers in the South, those in the Midwest used neuropsychological testing (OR=2.87, 95% confidence interval [CI] = 1.2-6.86; p=.018) and fluorodeoxyglucose-positron emission tomography (OR=2.74, 95% CI = = 1.14-6.61; p=.025) more commonly. For centers in the Northeast (OR = .46, 95% CI = .23-.93; p=.031) and West (OR = .41, 95% CI = .19-.87; p=.022), odds of performing single-photon emission computerized tomography were lower by nearly 50% compared to those in the South. Center accreditation level, demographics, volume, and resources were also associated with varying individual testing rates. Presurgical testing for drug-resistant epilepsy is influenced by US geographic region and other center characteristics. These findings have potential implications for comparing outcomes between US epilepsy centers and may inject disparities in access to surgical treatment.

Hippocampal recording via the RNS system reveals marked ipsilateral activation of epileptiform activity during Wada testing

Wada testing remains an important component of pre-surgical testing to assess the feasibility of temporal lobectomy for patients with intractable epilepsy. In this procedure, an anesthetic is injected into either internal carotid artery while memory and language testing is performed, simulating the effect of temporal lobe resection. The mechanism remains poorly understood because the hippocampal vasculature is predominantly via the posterior circulation. We recorded hippocampal EEG during bilateral methohexital Wada testing in three patients who had previously been implanted with a responsive neurostimulation system (RNS) to determine the effect of the injections on hippocampal activity. In all six injections from three patients, methohexital caused immediate, transient increases in hippocampal spikes. With at least two of these injections, the electrographic changes were consistent with electrographic seizures. In all cases, the epileptiform activity was not apparent on scalp EEG and was without obvious clinical correlate other than the negative findings expected from the anesthetic. The results demonstrate the utility of intracranial EEG during Wada testing and suggest that the elicitation of seizures or continuous spiking might contribute to dysfunction of the hippocampus during the Wada test. We hypothesize that this effect is due to disconnection and disinhibition of medial temporal structures.

INDISCRIMINATE COAGULATION TESTING FOR BLEEDING RISK ASSESSMENT PRIOR TO ORTHOPEDIC SURGERY. IS IT A RATIONAL APPROACH?

Abstract Objective: Indiscriminative preoperative coagulation testing to identify patients at risk of bleeding is commonly practiced. However, this practice is no longer supported by current recommendations. We conducted this study with an aim to evaluate the advantage of doing screening testing for coagulation and hemostasis in unselected patients prior to elective orthopedic surgeries in our setting. Material and Methods: It was a retrospective, cross sectional study carried out at Medicare Cardiac and General Hospital, Jinnah Medical and Dental College, Karachi. All the patients admitted for elective orthopedic bilateral total knee replacement and Hip replacement surgeries from March 2016 to December 2018 were included in the study. Electronic data of patients’ pre-operative test results for Prothrombin time, activated partial Thromboplastin time was retrieved. Frequency of patients with deranged coagulation screening was calculated. Results: A total of 367 patients underwent pre-surgical coagulation testing. Male to female ratio was 1:3. Median age of patients was 61±5 years. A total of 2.9% (n=11) patients were found to have deranged coagulation profile. Out of which 3 patients did not undergo surgery and were loss to follow up. Out of total 0.54% (n=2) patients had both prolonged PT and APTT, 1.6% (n=6) patients had prolonged APTT and 0.3% (n=1) patient experienced intraoperative bleeding requiring one unit of packed cell transfusion. Only 0.3% (n=1) patient experienced post-operative bleeding and dropped her Hemoglobin and received transfusion. Conclusion: The overall results of the study suggest that indiscriminate coagulation screening does not provide any additional information unless further detailed hemostatic evaluation is carried out. It is suggested that routine screening tests should not be performed unless a medical history is indicative of bleeding tendency. Key Words: Coagulation screening, Bleeding risk, Orthopedic surgery.

Effectiveness of Perioperative Cardiopulmonary Rehabilitation in Patients With Lung Cancer Undergoing Video-Assisted Thoracic Surgery.

ObjectivesPatients with lung cancer pose a high risk of morbidity and mortality after lung resection. Those who receive perioperative cardiopulmonary rehabilitation (PRCR) have better prognosis. Peak oxygen consumption (peak VO2), VO2 at the ventilatory threshold (VO2 at VT), and slope of minute ventilation to carbon dioxide production (VE/VCO2 slope) measured during pre-surgical cardiopulmonary exercise testing (CPET) have prognostic values after lung resection. We aimed to investigate the influence of individualized PRCR on postoperative complications in patients undergoing video-assisted thoracic surgery (VATS) for lung cancer with different pre-surgical risks.MethodsThis was a retrospective study. We recruited 125 patients who underwent VATS for lung cancer between 2017 and 2021. CPET was administered before surgery to evaluate the risk level and PRCR was performed based on the individual risk level defined by peak VO2, VO2 at VT, and VE/VCO2 slope, respectively. The primary outcomes were intensive care unit (ICU) and hospital lengths of stay, endotracheal intubation time (ETT), and chest tube insertion time (CTT). The secondary outcomes were postoperative complications (PPCs), including subcutaneous emphysema, pneumothorax, pleural effusion, atelectasis, infection, and empyema.ResultsThree intergroup comparisons based on the risk level by peak VO2 (3 groups), VO2 at VT (2 groups), and VE/VCO2 slope (3 groups) were done. All of the comparisons showed no significant differences in both the primary and secondary outcomes (p = 0.061–0.910).ConclusionPatients with different risk levels showed comparable prognosis and PPCs after undergoing CPET-guided PRCR. PRCR should be encouraged in patients undergoing VATS for lung cancer.

The Effects of The Covid-19 Pandemic on Pediatric Orthopaedic Sports Medicine &amp; Arthroscopy: Practice Implications, and The Management and Triaging of Surgical Cases

Background:The COVID-19 pandemic has had a significant impact on pediatric sports medicine patients. Many surgeons found themselves simultaneously managing surgical pathology, concerns of exposure, and limited resources. This led to challenging decisions regarding relative patient and case urgency.Purpose:1. Define through expert opinion the relative urgency of prototypical pediatric arthroscopic surgical cases 2. Define current practices regarding pre-surgical testing and findings relevant to the recent, current, and potentially forthcoming challenges inherent to the COVID-19 pandemic. We further gathered information regarding variability of current practices and access to resources.Methods:A mixed-methods survey was performed of the POSNA membership, specific to surgeons identifying as sub-specialized in pediatric sports medicine. A clinical vignette style survey was developed by the POSNA QSVI: Sports Committee. Cases included patients with a: meniscal tear, a bucket handle meniscus tear, ACL tear, unstable osteochondritis dissecans (OCD) lesion of the knee, locked knee due to a loose body, OCD of the capitellum, recurrent and primary shoulder instability, traumatic patellar instability with a loose osteochondral fragment, and a patient with a symptomatic discoid meniscus. The survey further asked how resource limitations could impact surgical decision-making, and how pre-operative testing might impact surgical timing and decisions. Information regarding personal and institutional experiences and limitations during the first 6 months of the pandemic was also collected.Results:There were 119 survey respondents, of whom 54 met inclusion criteria. Seventy-five percent were primarily based at a university or academic hospital. Almost 56% of respondents had all scheduled cases cancelled for 4-7 weeks, 22% for 8-11 weeks, and 17% were shut down for more than 12 weeks. Forty-two percent followed guidance from an orthopaedic governing body, most commonly national orthopaedic organizations. There was significant variation in pre-operative testing protocols, ranging from screening questions to PCR testing and rapid testing. Triaging factors chosen by respondents for determining relative urgency, in order, were: Diagnosis, severity of symptoms/pathology, duration of symptoms, age, activity level, originally planned surgical date, and patient request. Each clinical vignette elicited variability in responses, but each had clear leaders in opinion regarding relative urgency. Most cases had more than 2/3 of respondents in relative agreement with respect to urgency.Conclusion:This study provides comparative details of the challenges and resource limitations experienced in pediatric sports medicine, and provides much-needed sub-specialty opinions on standards with respect to relative urgency and triaging for related cases. These experiences and opinions may be of benefit when advocating for patient access and care.

Underutilization of advanced presurgical studies and high rates of vagus nerve stimulation for drug-resistant epilepsy: a single-center experience and recommendations.

Epilepsy surgery continues to be profoundly underutilized despite its safety and effectiveness. We sought to investigate factors that may contribute to this phenomenon, with a particular focus on the antecedent underutilization of appropriate preoperative studies. We reviewed patient data from a pediatric epilepsy clinic over an 18-month period. Patients with drug-resistant epilepsy (DRE) were categorized according to brain magnetic resonance imaging (MRI) findings (lesional, MRI-negative, or multifocal abnormalities) and type of epilepsy diagnosis based on semiology and electroencephalography (EEG) (focal or generalized). We then analyzed the rates of diagnostic test utilization, surgical referral, and subsequent epilepsy surgery as well as vagus nerve stimulation (VNS). Of the 249 patients with a diagnosis of epilepsy, 138 (55.4%) were found to have DRE. Excluding the 10 patients with DRE who did not undergo MRI, 76 patients (59.4%) were found to be MRI-negative (non-lesional epilepsy), 37 patients (28.9%) were found to have multifocal abnormalities, and 15 patients (11.7%) were found to have a single epileptogenic lesion on MRI (lesional epilepsy). Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) were each completed in nine patients (7.0%) and magnetoencephalography (MEG) in four patients (3.1%). Despite the low utilization rate of adjunctive studies, over half (56.3%) ultimately underwent VNS alone, and 8.6% ultimately underwent definitive intracranial resection or disconnection surgery. The underutilization of appropriate non-invasive, presurgical testing in patients with focal DRE may in part explain the continued underutilization of definitive, resective/disconnective surgery. For patients without access to a high-volume, multidisciplinary surgical epilepsy center, adjunctive presurgical studies [e.g., PET, SPECT, MEG, electrical source imaging (ESI), EEG-functional magnetic resonance imaging (fMRI)], even when available, are rarely ordered, and this may contribute to excessive rates of VNS in lieu of definitive intracranial surgery.