Neurosurgery
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Optimal postoperative pain control is critical after spinal fusion surgery. There remains significant variability in the use of postoperative intravenous opioid patient-controlled analgesia (PCA) and few data evaluating its utility compared with nurse-controlled analgesia (NCA) among patients with lumbar fusion. ⋯ Postoperative PCA is associated with significantly more opioid consumption in the first 72 h after surgery and equal or worse postoperative pain scores compared with NCA after lumbar spinal fusion surgery.
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Over 90 000 people are expected to be diagnosed with melanoma in the United States this year. The development of brain metastases is particularly difficult to manage. Over the past few years, melanoma patients with multiple unresectable brain metastases for which stereotactic surgery might also not be a viable option have fortunately experienced a dramatic expansion in available management options given improvements made to targeted agents, immunotherapy, and radiotherapy. ⋯ In this review, we summarize retrospective and prospective studies on individual advances in targeted agents, immunotherapy, and WBRT, highlighting important variables such as overall survival, intracranial progression-free survival, control and response rates, and toxicities. We also discuss the recent integration of these therapies into a multimodality approach, which has shown promise in the clinical setting although toxicities have not been insignificant. Finally, we describe ongoing prospective trials relevant to melanoma with brain metastases, and we conclude with our own thoughts on the optimal approach for these patients.
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Stereotactic radiosurgery (SRS) is a safe and effective treatment for acromegaly. ⋯ IGF-1i is a reliable predictor of biochemical remission after SRS. BED appears to predict biochemical outcome more reliably than radiation dose, but confirmatory study is needed.
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Observational Study
Predicting Long-Term Outcomes After Poor-Grade Aneurysmal Subarachnoid Hemorrhage Using Decision Tree Modeling.
Despite advances in the treatment of poor-grade aneurysmal subarachnoid hemorrhage (aSAH), predicting the long-term outcome of aSAH remains challenging, although essential. ⋯ Decision tree model is a simple tool for predicting long-term outcomes after poor-grade aSAH and may be considered for treatment decision-making.
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Multivariate risk prediction models individualize prediction of adverse outcomes, assisting perioperative decision-making. There are currently no models specifically designed for the neurosurgical population. ⋯ NZRISK-NEURO is a robust multivariate calculator created specifically for neurosurgery, enabling physicians to generate data-driven individualized risk estimates, assisting shared decision-making and perioperative planning.