Bringing high-grade arteriovenous malformations under control: clinical outcomes following multimodality treatment in children.

OBJECTIVE:Brain arteriovenous malformations (AVMs) consist of dysplastic blood vessels with direct arteriovenous shunts that can hemorrhage spontaneously. In children, a higher lifetime hemorrhage risk must be balanced with treatment-related morbidity. The authors describe a collaborative, multimodal strategy resulting in effective and safe treatment of pediatric AVMs. METHODS:A retrospective analysis of a prospectively maintained database was performed in children with treated and nontreated pediatric AVMs at the University of California, San Francisco, from 1998 to 2017. Inclusion criteria were age ≤ 18 years at time of diagnosis and an AVM confirmed by a catheter angiogram. RESULTS:The authors evaluated 189 pediatric patients with AVMs over the study period, including 119 ruptured (63%) and 70 unruptured (37%) AVMs. The mean age at diagnosis was 11.6 ± 4.3 years. With respect to Spetzler-Martin (SM) grade, there were 38 (20.1%) grade I, 40 (21.2%) grade II, 62 (32.8%) grade III, 40 (21.2%) grade IV, and 9 (4.8%) grade V lesions. Six patients were managed conservatively, and 183 patients underwent treatment, including 120 resections, 82 stereotactic radiosurgery (SRS), and 37 endovascular embolizations. Forty-four of 49 (89.8%) high-grade AVMs (SM grade IV or V) were treated. Multiple treatment modalities were used in 29.5% of low-grade and 27.3% of high-grade AVMs. Complete angiographic obliteration was obtained in 73.4% of low-grade lesions (SM grade I-III) and in 45.2% of high-grade lesions. A periprocedural stroke occurred in a single patient (0.5%), and there was 1 treatment-related death. The mean clinical follow-up for the cohort was 4.1 ± 4.6 years, and 96.6% and 84.3% of patients neurologically improved or remained unchanged in the ruptured and unruptured AVM groups following treatment, respectively. There were 16 bleeding events following initiation of AVM treatment (annual rate: 0.02 events per person-year). CONCLUSIONS:Coordinated multidisciplinary evaluation and individualized planning can result in safe and effective treatment of children with AVMs. In particular, it is possible to treat the majority of high-grade AVMs with an acceptable safety profile. Judicious use of multimodality therapy should be limited to appropriately selected patients after thorough team-based discussions to avoid additive morbidity. Future multicenter studies are required to better design predictive models to aid with patient selection for multimodal pediatric care, especially with high-grade AVMs

FoxP1 orchestration of ASD-relevant signaling pathways in the striatum

Mutations in the transcription factor Forkhead box p1 (FOXP1) are causative for neurodevelopmental disorders such as autism. However, the function of FOXP1 within the brain remains largely uncharacterized. Here, we identify the gene expression program regulated by FoxP1 in both human neural cells and patient-relevant heterozygous Foxp1 mouse brains. We demonstrate a role for FoxP1 in the transcriptional regulation of autism-related pathways as well as genes involved in neuronal activity. We show that Foxp1 regulates the excitability of striatal medium spiny neurons and that reduction of Foxp1 correlates with defects in ultrasonic vocalizations. Finally, we demonstrate that FoxP1 has an evolutionarily conserved role in regulating pathways involved in striatal neuron identity through gene expression studies in human neural progenitors with altered FOXP1 levels. These data support an integral role for FoxP1 in regulating signaling pathways vulnerable in autism and the specific regulation of striatal pathways important for vocal communication

Interictal Epileptiform Discharges and the Quality of Human Intracranial Neurophysiology Data.

Intracranial electroencephalography (IEEG) involves recording from electrodes placed directly onto the cortical surface or deep brain locations. It is performed on patients with medically refractory epilepsy, undergoing pre-surgical seizure localization. IEEG recordings, combined with advancements in computational capacity and analysis tools, have accelerated cognitive neuroscience. This Perspective describes a potential pitfall latent in many of these recordings by virtue of the subject population-namely interictal epileptiform discharges (IEDs), which can cause spurious results due to the contamination of normal neurophysiological signals by pathological waveforms related to epilepsy. We first discuss the nature of IED hazards, and why they deserve the attention of neurophysiology researchers. We then describe four general strategies used when handling IEDs (manual identification, automated identification, manual-automated hybrids, and ignoring by leaving them in the data), and discuss their pros, cons, and contextual factors. Finally, we describe current practices of human neurophysiology researchers worldwide based on a cross-sectional literature review and a voluntary survey. We put these results in the context of the listed strategies and make suggestions on improving awareness and clarity of reporting to enrich both data quality and communication in the field

Interictal Epileptiform Discharges and the Quality of Human Intracranial Neurophysiology Data.

Intracranial electroencephalography (IEEG) involves recording from electrodes placed directly onto the cortical surface or deep brain locations. It is performed on patients with medically refractory epilepsy, undergoing pre-surgical seizure localization. IEEG recordings, combined with advancements in computational capacity and analysis tools, have accelerated cognitive neuroscience. This Perspective describes a potential pitfall latent in many of these recordings by virtue of the subject population-namely interictal epileptiform discharges (IEDs), which can cause spurious results due to the contamination of normal neurophysiological signals by pathological waveforms related to epilepsy. We first discuss the nature of IED hazards, and why they deserve the attention of neurophysiology researchers. We then describe four general strategies used when handling IEDs (manual identification, automated identification, manual-automated hybrids, and ignoring by leaving them in the data), and discuss their pros, cons, and contextual factors. Finally, we describe current practices of human neurophysiology researchers worldwide based on a cross-sectional literature review and a voluntary survey. We put these results in the context of the listed strategies and make suggestions on improving awareness and clarity of reporting to enrich both data quality and communication in the field

COVID-19 Radiology Preparedness, Challenges & Opportunities: Responses From 18 Countries.

PurposeRadiology departments around the world have been faced with the challenge to adapt, and recover to the COVID-19 pandemic. This study is part of a worldwide survey of radiologists' responses to COVID-19 in 18 different countries in Africa, Asia, Europe, and Latin America. The purpose of this study is to analyze the changes made in international radiology departments and practices in response to the pandemic.MethodsThe 18-item survey was sent via email from April to May 2020 to radiologists in Africa, Asia, Europe, and Latin America to assess their response to COVID-19. Our survey included questions regarding imaging, workforce adjustments, testing availability, staff and patient safety, research and education, and infrastructure availability.ResultsTwenty-eight survey responses were reviewed. Of the 28 respondents, 42.9% have shortages of infrastructure and 78.6% responded that COVID-19 testing was available. Regarding the use of Chest CT in COVID-19 patients, 28.6% respondents used Chest CT as screening for COVID-19. For staff safety, interventions included encouraging use of masks in patient encounters, social distancing and PPE training. To cope with their education and research mission, radiology departments are doing online lectures, reducing the number of residents in rotations, and postponing any non-urgent activities.ConclusionIn conclusion, there are disparities in infrastructure, research, and educational initiatives during COVID-19 which also provides opportunity for the global radiology community to work together on these issues

Perioperative Anesthesia Lean Implementation Is Associated With Increased Operative Efficiency in Posterior Cervical Surgeries at a HighVolume Spine Center.

OBJECTIVE:Lean management strategies aim to increase efficiency by eliminating waste or by improving processes to optimize value. The operating room (OR) is an arena where these strategies can be implemented. We assessed changes in OR efficiency after the application of lean methodology on perioperative anesthesia associated with posterior cervical spine surgeries. METHODS:We utilized pre- and post-lean study design to identify inefficiencies during the perioperative anesthesia process and implemented strategies to improve the process. Patient characteristics were recorded to assess for differences between the 2 groups (group 1, prelean; group 2, post-lean). In the pre-lean period, key steps in the perioperative anesthesia process were identified that were amenable to lean implementation. The time required for each identified key step was recorded by an independent study coordinator. The times for each step were then compared between the groups utilizing univariate analyses. RESULTS:After lean implementation, there was a significant decrease in overall perioperative anesthesia process time (88.4 ± 4.7 minutes vs. 76.2 ± 3.2 minutes, p = 0.04). This was driven by significant decreases in the steps: transport and setup (10.4 ± 0.8 minutes vs. 8.0 ± 0.7 minutes, p = 0.03) and positioning (20.8 ± 2.1 minutes vs. 15.7 ± 1.3 minutes, p = 0.046). Of note, the total time spent in the OR was lower for group 2 (270.1 ± 14.6 minutes vs. 252.8 ± 14.1 minutes) but the result was not statistically significant, even when adjusting for number of operated levels. CONCLUSION:Lean methodology may be successfully applied to posterior cervical spine surgery whereby improvements in the perioperative anesthetic process are associated with significantly increased OR efficiency