Neurosurgery
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Checkpoint molecules like programmed death-1 (PD-1) and T-cell immunoglobulin mucin-3 (TIM-3) act as negative regulators of the immune system and can be upregulated in the setting of glioblastoma multiforme (GBM). Combined PD-1 blockade and stereotactic radiosurgery (SRS) have been shown to improve antitumor immunity and produce long-term survivors in a murine glioma model. However, tumor-infiltrating lymphocytes can express multiple checkpoints (including TIM-3), and expression of 2 or more checkpoints corresponds to a more exhausted T-cell phenotype. Here, we hypothesized that the addition of a second checkpoint-blocking antibody could achieve additive or synergistic antitumor effects. ⋯ Combining anti-TIM-3 with anti-PD-1 and radiation was synergistic and conferred a significant survival benefit.
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MRI-guided stereotactic laser amygdalohippocampotomy (SLAH) is a minimally invasive and effective alternative to open temporal lobe surgery in appropriately selected patients. We have previously demonstrated SLAH to be most effective for patients with mesial temporal sclerosis (MTS) on preoperative MRI. Nevertheless, patients who do not achieve seizure freedom may benefit from additional procedures. The feasibility, safety, and efficacy of repeat laser ablation of remaining mesial temporal structures have not been reported. ⋯ While SLAH alone is effective for select patients with mesial temporal lobe epilepsy, this preliminary study indicates that additional extended ablation of extrahippocampal mesial temporal structures may provide additional relief from recurrent seizures. Additional subjects, longer outcomes, and neurocognitive assessments are pending.
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Direct brain stimulation is thought to produce a temporary lesion effect to the surrounding tissue and the synaptically connected network. In the medial temporal lobe (MTL), application of electrical current has been shown to produce memory impairments, but the nature of this effect is unknown. ⋯ We interpret our findings as support for a rapid contextual change account of stimulation-induced forgetting. Stimulation of the MTL may have disrupted neural activity representing temporal context, and thus impaired the internally generated memory search. Alternatively, an interruption of list item maintenance may explain impaired performance. By continuing to refine the cognitive understanding of forgetting-induced MTL stimulation, future research may lead to selective pruning of unwanted memories.
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Both transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) are effective surgical interventions for patients with degenerative lumbar spondylosis. We sought to compare health care costs by calculating the incremental cost-effectiveness ratio and, thereby, the difference in the total cost per quality-adjusted life-year (QALY) gained for TLIF vs LLIF for the treatment of degenerative spondylosis. We further calculated the thresholds for minimum clinically important difference (MCID) and minimum cost-effective difference (MCED) for patient-reported outcome measures at 2-year follow-up. ⋯ TLIF and LLIF produced equivalent 2-year patient outcomes at an equivalent cost-effectiveness profile.
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Value-base purchasing and pay-for-performance models are driving the development of bundle payment systems for reimbursement. To build a sustainable bundling system, it is important to identify the contributions of each component of index surgery total cost and determine the domain where targeted savings can occur. We determined the percent contribution of health care resource utilization, hospital fee, surgeon's fee, and readmission to total cost of index surgery following elective spine surgery. ⋯ Hospital fee had the largest contribution (75%) to the total cost of index surgery, followed by readmissions (21%). Surgeon's fee and health care resource utilization had much smaller contributions to total cost. True cost savings can occur through engagement and partnering between hospital and surgeon to decrease hospital fees. Reducing readmission episodes and understanding and reducing modifiable drivers of hospital fees have the potential to decrease total direct cost for elective spine surgery.