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Silencing the Noise: State-Of-The-Art Neuroendovascular and Cardiology Management of Pulsatile Tinnitus
No full textPulsatile tinnitus (PT) is a unique clinical condition often attributed to various vascular anomalies, making it of increasing interest to specialists outside the traditional realms of otolaryngology and neurology. Endovascular treatment has recently emerged as a key management tool for patients suffering from PT, particularly in cases associated with venous sinus stenosis or arteriovenous shunting. Understanding the indications, procedural risks, and long-term outcomes associated with endovascular treatment is important to ensure timely referral and comprehensive care for patients presenting with PT. Cardiologists should be vigilant for signs and symptoms of PT, as PT can be an early indicator of vascular abnormalities and other cardiovascular conditions. Once identified, cardiologists can play an essential role in the timely diagnosis and treatment of PT, differentiating the etiology and ensuring that the patient receives the proper prompt referrals for imaging and endovascular assessment if needed
You Cannot Manage What You Do Not Measure Advances in Global Stroke Interventions and the Role of the Mechanical Thrombectomy Access Score
No full textGlobal disparities in stroke care, particularly in acute interventions like mechanical thrombectomy (MT), remain profound, with the Mechanical Thombectomy Global Access for Stroke study reporting a median global MT access of just 2.79%. Furthermore, the low- and middle-income countries (LMICs) have been recognized to be disproportionately burdened in this regard as compared with high-income countries. These observed inequities in stroke care impact not only clinical outcomes but also economic productivity and social systems. Recent advancements, such as TeleStroke networks, Mobile Stroke Units, and artificial intelligence-powered tools, have the potential to bridge these gaps. The Mechanical Thrombectomy Access Score (MTAS) offers a novel standardized approach to quantifying barriers to MT access and guiding targeted interventions to mitigate such obstacles. This review explores how MTAS enables the integration of these advancements into global stroke care systems, addressing inequities and optimizing outcomes. Emphasizing the importance of measuring access to manage inequities, we propose strategies to refine and validate MTAS while advocating for systemic investments to enhance global stroke care
Feasibility of Obtaining Intraoperative Electrically Evoked Stapedial Reflex Thresholds (Esrt)
No full textObjectives: To assess the rate of obtaining intraoperative eSRT measurements in primary cochlear implant (CI) recipients while limiting the use of volatile anesthetics, such as sevoflurane. Methods: In this prospective cohort study, thirty-one patients who underwent CI surgery with a Cochlear Americas device from January 2023 through March 2024 were included. Intraoperative eSRT testing at electrodes E1, E6, E12, E17, and E22 was performed on all patients. Sevoflurane was discontinued and confirmed undetectable at least 10 min prior to eSRT testing to avoid diminishing the stapedial reflex. The primary outcome measure was eSRT response rate at any electrode or pulse width. Results: Thirty-four CIs were placed in 31 patients, including three bilateral recipients. Eighty-five percent (29/34) of implants had at least one response at any electrode or pulse width; 71% (24/34) at pulse width 25 μs; and 82% (28/34) at 25 or 37 μs. Response rates were significantly higher at apical (E17, E22) and middle (E12) electrodes compared to basal electrodes (E1, E6) (p = 0.004). Comparisons also revealed significantly different eSRT values between apical, middle, and basal electrodes (p \u3c 0.0001). Specifically, the basal electrode region had a greater median threshold (30.5 nC/phase) than apical (18.3 nC/phase; p \u3c 0.0001) and middle (17.7 nC/phase; p \u3c 0.001) regions. Conclusion: Intraoperative eSRT is a feasible and effective way of obtaining an objective measurement that can potentially guide CI programming. Subsequent studies will investigate the relationship between intraoperative and postoperative eSRT in this patient cohort and determine how intraoperative eSRT may facilitate CI programming. Level of Evidence: 2
Contemporary Biology, Management, and Outcomes of Renal Medullary Carcinoma in Children and Adults: A Pediatric Surgical Oncology Research Collaborative Study
No full textBackground: Renal medullary carcinoma (RMC) is an aggressive tumor associated with sickle cell trait. Despite treatment advances for other rare renal tumors, RMC survival remains poor. We aimed to describe the contemporary management and survival of children and adults with RMC. Procedure: In this multicenter retrospective cohort study, Pediatric Surgical Oncology Research Collaborative sites searched their databases for patients diagnosed with RMC (2000–2022). Descriptive statistics were calculated and survival analyses performed using Kaplan–Meier and Cox regression. Results: Thirty-four patients with RMC were identified. Median age was 19 years (IQR: 15–28; range: 7–52). Most were male (24/34; 71%), Black (27/32; 84%), had sickle cell trait or disease (30/33; 91%), presented with metastatic disease (27/34; 79%), and were symptomatic at presentation (32/34; 94%). Median overall survival (OS) was 24 months from diagnosis (16 months for children, 28 months for adults, p = 0.6). Receipt of platinum-based chemotherapy (23/34; 68%) was associated with significantly higher OS than other regimens (35 vs. 5 months, p \u3c 0.001). Nephrectomy (24/34; 71%) was associated with significantly improved OS compared with non-operative management (34 vs. 7 months, p = 0.001). Immunotherapy, targeted therapy, or radiation therapy were not associated with significant differences in OS, nor were age, sex, race, sickle cell status, SMARCB1/INI-1, stage, nephrectomy approach, retroperitoneal lymph node dissection, gross residual disease, margins, or tumor size. Conclusions: RMC survival remains poor despite newer therapies. Nephrectomy and platinum-based chemotherapy should be considered in locally advanced and metastatic disease. Coordinated international cooperative group studies are needed to meaningfully improve RMC survival
‘Transient Immediate Orthostatic Hypotension’ Is Preferable to ‘Initial’ Orthostatic Hypotension
No full textA drop of systemic blood pressure (BP) occurring shortly after individuals move from supine or seated position to upright posture with subsequent prompt spontaneous resolution is a common physiological occurrence in humans. If the induced hypotension is severe, lightheadedness or postural instability leading to falls and injury may occur. By consensus, a transient systolic BP drop \u3e40 mmHg within 15 s of standing is deemed abnormal and has become termed ‘initial orthostatic hypotension’ (initial OH, iOH). However, the term ‘initial OH’ implies that another hypotensive event will follow shortly. In essence, if an OH event is deemed to be ‘initial’, then one might reasonably assume that a subsequent OH event is imminent. However, in the setting of abrupt movement to upright posture, the BP drop is usually solitary and brief (resolution within 15–30 s); thereafter the individual is usually OH symptom-free until they undertake another similar postural change. Currently, there is no single descriptor for a posture change driven, short-lived, spontaneously resolving OH event, without the implication that further hypotension is imminent as is implied by the term ‘initial OH’. In order to foster more accurate nomenclature, we recommend that ‘initial OH’ be retired, and ‘immediate OH’ or transient ‘immediate OH’ be substituted. While ‘immediate’ OH may be imperfect, it conveys an early onset event without implying additional imminent OH. Thus immediate OH or transient immediate are more accurate descriptors of this common transient hypotensive event. The abbreviation, ‘iOH’, remains unchanged
A Minimally Invasive Technique for Ventriculoatrial Shunt Placement
No full textVentriculoperitoneal shunts (VPS) is a first-line option in the surgical management of hydrocephalus. However, a ventriculoatrial shunt (VAS) becomes valuable in conditions where cerebrospinal fluid drainage into the abdomen is unsuitable. Although the VAS technique has been described in previous studies, we present a minimally invasive approach supplemented with step-by-step image and video guidance. Based on our experience with over 200 cases, we have developed a safe and efficient technique for VAS placement. We further discuss the surgical setup, procedure, and complications associated with VAS placement. This procedure should be individualized, considering the patient\u27s anatomy and pathology. Overall, VAS procedure is a reliable, safe, and simple to learn alternative for the management of hydrocephalus in patients with compromised peritoneum or contraindication to VPS
Pharmacokinetic Evaluation of Aripiprazole Monohydrate as a Once Every 2-Months Long-Acting Injectable Antipsychotic for Schizophrenia
No full textIntroduction: Long-acting injectable (LAI) antipsychotics are often considered preferable to their oral counterparts for the long-term maintenance treatment of schizophrenia. One goal of LAI drug development is to extend the dose interval between injection visits. Aripiprazole Monohydrate (AM, Abilify Maintena®) was approved in 2013 as a monthly formulation, but a 2-month interval formulation (Ari2M, Abilify Asimtufii®) was approved by the FDA in 2023 for the treatment of schizophrenia in adults and maintenance monotherapy of bipolar I disorder in adults, and by the EMA as Abilify Maintena® 960 mg in 2024 with the indication of maintenance treatment of schizophrenia in adult patients stabilized with oral aripiprazole. Areas covered: This review covers the development and pharmacokinetics of the 2-month formulation and provides data on the safety and pharmacokinetic modeling which informed its regulatory approval. Expert opinion: Ari2M 960 mg Q2M can be safely substituted for AOM 400 mg Q1M and Ari2M 720 mg Q2M for AOM 300 mg Q1M as per clinician and patient preference. The new formulation employs a ready-to-use prefilled syringe, must be administered in the gluteal muscle, and can be given within ± 2 weeks of the scheduled injection date. Reinitiation is only necessary if ≥ 14 weeks have passed since the prior injection