Neurosurgery
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EGFRvIII, a constitutively active EGFR deletion driver mutation, is associated with poor long-term survival in glioblastoma (GB). The investigational vaccine rindopepimut consists of a peptide sequence unique to EGFRvIII conjugated to keyhole limpet hemocyanin (KLH), delivered intradermally with granulocyte macrophage colony-stimulating factor. Three phase II studies in newly diagnosed, resected, EGFRvIII+ GB demonstrated encouraging progression-free survival (PFS), overall survival (OS), and safety profile. Compassionate-use experience suggests that rindopepimut may also provide benefit in relapsed GB, particularly with agents such as bevacizumab (BV). ⋯ These near-final data show that rindopepimut induces potent EGFRvIII-specific immune response and tumor regression, and appears to significantly prolong survival when administered with BV in patients with relapsed GB.
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Radiation exposure from diagnostic imaging is a significant concern, particularly in the care of pediatric patients. Computed tomography (CT) scanning is a significant source of radiation. ⋯ Although replacing a CT with magnetic resonance imaging is ideal to completely avoid ionizing radiation, this is not always practical or preferred. Therefore, it is important to have CT protocols in place that minimize radiation dose without sacrificing diagnostic quality. The protocols in place at our institution could be replicated at other academic and community hospitals and imaging centers.
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Previous studies have documented dysfunctional cerebral metabolism following traumatic brain injury (TBI), characterized by reduction in cerebral metabolic rates (CMRs) of glucose and oxygen. In our largest series to date, here, we provide further evidence and time courses of these metabolic changes. ⋯ In our largest series of patients to date, we have demonstrated that posttraumatic cerebral metabolism is characterized by depressed glucose and oxygen metabolism that is persistent for at least 6 days postinjury. There is mismatch between glucose and oxygen utilization, indicated by diminished metabolic ratio, and frequent lactate uptake. Further study is required to fully characterize the dysfunctional metabolism, which may be a source of further secondary injury in the early postinjury period.
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Delivery of higher-value health care is an ultimate government and public goal. Improving efficiency in the operating room and standardization of surgical steps would improve patient outcome and reduce costs, and lead to higher-value health care. Lean principles have been applied to processes proceeding and following surgery and have improved timeliness; however, value stream mapping of surgery itself has not been performed; therefore, pure waste has not been targeted for improvement. We applied plan, do, study, act (PDSA) cycles to posterior instrumented fusion (PIF) in an attempt create a standard work flow, identify waste, and remove special cause variability among similar cases. ⋯ Lean principles can be applied to neurosurgical procedure time, and can be used to standardize surgical workflow and identify waste; common to all procedures was waiting and defect waste from nonsurgical sources. These preliminary data were the basis of a quality improvement Kaizen event to decrease the causes of variability, improve efficiency, and decrease overall cost.
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Biochemical alterations associated with mechanical stress have been explored as an initiating step in the pathological progression of ligamentum flavum hypertrophy (LFH); however, this mechanism remains poorly understood. Recently, the inflammation induced after mechanical stress and the subsequent response of ligamentum flavum (LF) cells have been implicated in LFH pathology. ⋯ The LSCS group showed greater segmental motion, higher VEGF concentrations, and more CD34-positive capillaries than the control group. These data indicate that VEGF-mediated angiogenesis following mechanical stress may be a critical step within the series of pathological events in LFH.