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Ploesser M, McDonald C, Hirshman B, Ben-Haim S. Psychiatric outcomes after temporal lobe surgery in patients with temporal lobe epilepsy and comorbid psychiatric illness: A systematic review and meta-analysis. Epilepsy Res 2023; 189:107054. [PMID: 36473277 DOI: 10.1016/j.eplepsyres.2022.107054] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/05/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The currently available evidence is unclear in regard to psychiatric outcomes of temporal lobe epilepsy (TLE) in patients with comorbid psychiatric disorders (PD). AIM To identify and synthesize psychiatric outcomes in patients with TLE and comorbid psychiatric illnesses before and after TLE surgery. METHODS Studies were included if participants were adults and/or children with temporal epilepsy and comorbid psychiatric illness. Surgical interventions included focal resection (e.g., lobectomy, selective amygdalohippocampectomy) or stereotactic laser ablation. Included studies reported on pre- and post- surgery data of comorbid psychiatric illness (e.g., mood and anxiety disorders, depression, psychosis, adjustment disorders, non-epileptic seizures, and personality disorders). RESULTS Ten studies were included in the review. The proportion of patients achieving PD resolution or improvements after surgery varied widely between studies, ranging from 15 % to 57 % at the reported follow-up time. Three studies reported on PD symptom worsening after surgery, with considerable variations of patient proportions across studies. Meta-analysis suggests that 43 % of patients demonstrated improvement and 33 % of patients showed a worsening in psychiatric scores across all studies. Preliminary data from three studies suggest that seizure control may be associated with favourable psychiatric outcomes. CONCLUSION A considerable proportion of reported TLE patients with comorbid psychiatric illnesses have improvement in their psychiatric symptoms after temporal lobe epilepsy surgery. There is scarcity of detailed outcome reporting including symptom scores, and to date, predictive factors for favourable vs unfavourable outcomes in this patient population are not clear. Further research on the topic is warranted.
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Affiliation(s)
- Markus Ploesser
- Department of Psychiatry & Neuroscience, UC Riverside School of Medicine, 900 University Ave. Riverside, CA 92521, USA; University of British Columbia, Division of Forensic Psychiatry, Department of Psychiatry, Faculty of Medicine, Detwiller Pavilion, 2255 Wesbrook Mall, Vancouver BC V6T 2A1, Canada.
| | - Carrie McDonald
- Department of Psychiatry, University of California San Diego, 9500 Gillman Drive, La Jolla, CA 92093, USA
| | - Brian Hirshman
- Department of Neurological Surgery, University of California San Diego, 9300 Campus Point Drive, La Jolla, CA 92037, USA
| | - Sharona Ben-Haim
- Department of Neurological Surgery, University of California San Diego, 9300 Campus Point Drive, La Jolla, CA 92037, USA
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2
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Stone LE, Goodwill V, Wali AR, Hirshman B, Santiago-Dieppa DR, Khalessi A. Subarachnoid Hemorrhage as a Consequence of Pleomorphic Xanthoastrocytoma: A Case Report. Neurosurg open 2021. [DOI: 10.1093/neuopn/okab020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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3
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Alattar AA, Carroll KT, Bryant AK, Hirshman B, Joshi R, Carter BS, Harismendy O, Chen CC. Prognostic Importance of Age, Tumor Location, and Tumor Grade in Grade II Astrocytomas: An Integrated Analysis of the Cancer Genome Atlas and the Surveillance, Epidemiology, and End Results Database. World Neurosurg 2019; 121:e411-e418. [DOI: 10.1016/j.wneu.2018.09.124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/16/2018] [Indexed: 12/27/2022]
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4
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Alattar A, Carroll K, Bryant A, Hirshman B, Joshi R, Carter B, Harismendy O, Chen C. SURG-04. SURVIVAL BENEFIT ASSOCIATED WITH GROSS TOTAL RESECTION IN GRADE II ASTROCYTOMAS: AN INTEGRATED ANALYSIS OF THE SEER AND TCGA DATABASE. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.1040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ali Alattar
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Kate Carroll
- University of Washington Department of Neurological Surgery, Seattle, WA, USA
| | - Alex Bryant
- University of Michigan Ann Arbor Department of Radiation Oncology, Ann Arbor, MI, USA
| | - Brian Hirshman
- University of California San Diego Department of Neurosurgery, San Diego, CA, USA
| | - Rushikesh Joshi
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Bob Carter
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Clark Chen
- University of Minnesota Department of Neurosurgery, Minneapolis, MN, USA
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5
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Alattar A, Hirshman B, Joshi R, Chen C. CMET-18. RISK FACTORS FOR CEREBRAL EDEMA AFTER STEREOTACTIC RADIOSURGERY FOR BRAIN METASTASES. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ali Alattar
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Brian Hirshman
- University of California San Diego Department of Neurosurgery, San Diego, CA, USA
| | - Rushikesh Joshi
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Clark Chen
- University of Minnesota Department of Neurosurgery, Minneapolis, MN, USA
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6
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Alattar A, Hirshman B, Joshi R, Chen C. CMET-23. NATURAL HISTORY AND RISK FACTORS FOR CYSTIC FORMATION AFTER STEREOTACTIC RADIOSURGERY FOR BRAIN METASTASIS. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ali Alattar
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Brian Hirshman
- University of California San Diego Department of Neurosurgery, San Diego, CA, USA
| | - Rushikesh Joshi
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Clark Chen
- University of Minnesota Department of Neurosurgery, Minneapolis, MN, USA
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7
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Alattar A, Hirshman B, Joshi R, Chen C. CMET-17. VENTRICULOMEGALY AFTER STEREOTACTIC RADIOSURGERY FOR BRAIN METASTASES. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ali Alattar
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Brian Hirshman
- University of California San Diego Department of Neurosurgery, San Diego, CA, USA
| | - Rushikesh Joshi
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Clark Chen
- University of Minnesota Department of Neurosurgery, Minneapolis, MN, USA
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8
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Ramakrishnan V, Akers J, Nguyen T, Wang A, Adhikari B, Hirshman B, Li J, Sarkaria J, Hua W, Ying M, Nitta M, Jiang T, Carter B, Chen CC. Abstract 1956: miR-181d degradation mediated genetic heterogeneity and acquired resistance. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-1956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
When unrepaired, alkylated DNA can induce cell death or trigger mutagenesis. Cellular capacity for repair of these lesions by O6-methylguanine methyltransferase (MGMT) dictates the equilibrium between cell viability and genetic diversity. Treatment of glioblastoma cells with temozolomide (TMZ) induced ATM- and Rad3-related (ATR) kinase dependent polyribonucleotide nucleotidyltransferase 1 (PNPT1) degradation of miR-181d. miR-181d suppresses MGMT expression; its degradation increases the mean MGMT expression of the cell population. miR-181d degradation also magnifies the cell-to-cell variability in MGMT expression, expanding the genetic heterogeneity of the population. This expanded heterogeneity enhances the “fitness” of the population and constitutes a novel form of chemotherapeutic resistance. These effects can be suppressed by overexpression of miR-181d, suggesting miRNA delivery as a strategy for glioblastoma therapy. To characterize the mechanism of acquired resistance, we profiled the expression of 2400 miRNAs before and after TMZ treatment. In independent patient-derived neurosphere lines, the majority of miRNAs remained unchanged after treatment. However, miR-181d was consistently suppressed after TMZ treatment. Our previous work demonstrated miR-181d as the master regulator of MGMT. We confirmed TMZ-induced suppression of miR-181d using independent in vitro and in vivo models as well as matched pre- and post-TMZ treated clinical specimens. TMZ-induced miR-181d suppression persisted after transcriptional inhibition, suggesting degradation as the primary mechanism. We performed an siRNA screen and identified polyribonucleotide nucleotidyltransferase 1 (PNPT1) as the gene responsible for miR-181d degradation. CRISPR inactivation of PNPT1 eliminated TMZ-induced suppression of miR-181d; this was rescued by wild-type PNPT1 but not by PNPT1 harboring RNAse-inactivating mutations. TMZ-induced degradation of miR-181d requires ATR kinase. Silencing or inhibition of ATR eliminated binding of PNPT1 to miR-181d and prevented degradation of miR-181d. TMZ-sensitizing effects of ATR inhibition were reversed by anti-miR-181d, suggesting miR-181d is essential in this process. In addition to elevating the mean MGMT expression of the population, single-cell analysis revealed that miR-181d degradation broadened the cell-to-cell variability in MGMT expression in vitro. In matched clinical pre- and post-TMZ treated specimens, variability in MGMT expression was significantly elevated in post-TMZ samples. This was recapitulated using The Cancer Genome Atlas (TCGA) database. We propose that miR-181d degradation-mediated expansion of genetic heterogeneity enhances the “fitness” of the population, constituting a novel form of chemotherapeutic resistance. These effects are suppressed by miR-181d overexpression, suggesting miRNA delivery as a strategy for glioblastoma therapy.
Citation Format: Valya Ramakrishnan, Johnny Akers, Thien Nguyen, Aaron Wang, Bandita Adhikari, Brian Hirshman, Jie Li, Jann Sarkaria, Wei Hua, Mao Ying, Masayuki Nitta, Tao Jiang, Bob Carter, Clark C. Chen. miR-181d degradation mediated genetic heterogeneity and acquired resistance [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1956.
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Affiliation(s)
| | - Johnny Akers
- 2University of California San Diego, San Diego, CA
| | - Thien Nguyen
- 2University of California San Diego, San Diego, CA
| | - Aaron Wang
- 2University of California San Diego, San Diego, CA
| | | | | | - Jie Li
- 1University of Minnesota, Minneapolis, MN
| | | | - Wei Hua
- 4Fudan University, Shanghai, China
| | - Mao Ying
- 4Fudan University, Shanghai, China
| | | | - Tao Jiang
- 6Capital Medical University, Beijing, China
| | - Bob Carter
- 2University of California San Diego, San Diego, CA
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9
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Carroll KT, Bryant AK, Hirshman B, Alattar AA, Joshi R, Gabel B, Carter BS, Harismendy O, Vaida F, Chen CC. Interaction Between the Contributions of Tumor Location, Tumor Grade, and Patient Age to the Survival Benefit Associated with Gross Total Resection. World Neurosurg 2018; 111:e790-e798. [PMID: 29309983 DOI: 10.1016/j.wneu.2017.12.165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 12/24/2017] [Accepted: 12/27/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Gross total resection (GTR) in patients with glioblastoma (GB) and anaplastic astrocytoma (AA) is associated with improved survival. We examined how tumor location, tumor grade, and age affected this benefit. METHODS We selected patients with lobar AA or GB in the Surveillance, Epidemiology, and End Results database from 1999 to 2010. Survival analyses were performed using Kaplan-Meier curves and Cox proportional hazards models. RESULTS We identified and studied 1429 patients with lobar AA and 12,537 patients with lobar GB in the Surveillance, Epidemiology, and End Results database. In multivariate Cox proportional hazards analysis, GTR of frontal lobe AA was associated with approximately 50% reduction in risk of death compared with subtotal resection (STR) (hazard ratio 0.51; 95% confidence interval, 0.36-0.73; P < 0.001). This hazard ratio corresponds to a median increase in overall survival of >8 years with GTR compared with STR. In nonfrontal AAs, there was no survival difference between GTR and STR (hazard ratio 0.79; 95% confidence interval, 0.58-1.08; P = 0.143). Location-specific survival benefit from GTR in AAs was significant in patients ≤50 years old but was not evident in patients >50 years old. In patients with GB, no location-dependent survival benefit with GTR was observed. CONCLUSIONS Our results demonstrate complex interaction between tumor grade, frontal lobe location, and age in their various contributions to survival benefit gained from GTR. The greatest survival benefit of GTR relative to STR was observed in patients ≤50 years old with frontal AAs.
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Affiliation(s)
- Kate T Carroll
- School of Medicine, University of California, San Diego, San Diego, California, USA
| | - Alex K Bryant
- School of Medicine, University of California, San Diego, San Diego, California, USA
| | - Brian Hirshman
- Department of Neurosurgery, University of California, San Diego, San Diego, California, USA
| | - Ali A Alattar
- School of Medicine, University of California, San Diego, San Diego, California, USA
| | - Rushikesh Joshi
- School of Medicine, University of California, San Diego, San Diego, California, USA
| | - Brandon Gabel
- Department of Neurosurgery, University of California, San Diego, San Diego, California, USA
| | - Bob S Carter
- Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Olivier Harismendy
- Moores Cancer Center, University of California, San Diego, San Diego, California, USA
| | - Florin Vaida
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California, USA
| | - Clark C Chen
- Department of Neurosurgery, University of California, San Diego, San Diego, California, USA; Moores Cancer Center, University of California, San Diego, San Diego, California, USA.
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10
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Khalil S, Fabbri E, Santangelo A, Bezzerri V, Cantù C, Di Gennaro G, Finotti A, Ghimenton C, Eccher A, Dechecchi M, Scarpa A, Hirshman B, Chen C, Ferracin M, Negrini M, Gambari R, Cabrini G. miRNA array screening reveals cooperative MGMT-regulation between miR-181d-5p and miR-409-3p in glioblastoma. Oncotarget 2018; 7:28195-206. [PMID: 27057640 PMCID: PMC5053720 DOI: 10.18632/oncotarget.8618] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 03/25/2016] [Indexed: 11/25/2022] Open
Abstract
The levels of expression of O6-methylguanine-DNA methyltransferase (MGMT) are relevant in predicting the response to the alkylating chemotherapy in patients affected by glioblastoma. MGMT promoter methylation and the published MGMT regulating microRNAs (miRNAs) do not completely explain the expression pattern of MGMT in clinical glioblastoma specimens. Here we used a genome-wide microarray-based approach to identify MGMT regulating miRNAs. Our screen unveiled three novel MGMT regulating miRNAs, miR-127-3p, miR-409-3p, and miR-124-3p, in addition to the previously identified miR-181d-5p. Transfection of these three novel miRNAs into the T98G glioblastoma cell line suppressed MGMT mRNA and protein expression. However, their MGMT- suppressive effects are 30–50% relative that seen with miR-181d-5p transfection. In silico analyses of The Cancer Genome Atlas (TCGA) and Chinese Glioma Genome Atlas (CGGA) revealed that miR-181d-5p is the only miRNA that consistently exhibited inverse correlation with MGMT mRNA expression. However, statistical models incorporating both miR-181d-5p and miR-409-3p expression better predict MGMT expression relative to models involving either miRNA alone. Our results confirmed miR-181d-5p as the key MGMT-regulating miRNA. Other MGMT regulating miRNAs, including the miR-409-3p identified in this report, modify the effect of miR-181d-5p on MGMT expression. MGMT expression is, thus, regulated by cooperative interaction between key MGMT-regulating miRNAs.
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Affiliation(s)
- Susanna Khalil
- Department of Pathology and Diagnostics, Laboratory of Molecular Pathology, University Hospital, Verona, Italy
| | - Enrica Fabbri
- Department of Life Sciences and Biotechnology, Section of Biochemistry and Molecular Biology, University of Ferrara, Ferrara, Italy
| | - Alessandra Santangelo
- Department of Pathology and Diagnostics, Laboratory of Molecular Pathology, University Hospital, Verona, Italy
| | - Valentino Bezzerri
- Department of Pathology and Diagnostics, Laboratory of Molecular Pathology, University Hospital, Verona, Italy
| | - Cinzia Cantù
- Department of Pathology and Diagnostics, Laboratory of Molecular Pathology, University Hospital, Verona, Italy
| | - Gianfranco Di Gennaro
- Department of Pathology and Diagnostics, Laboratory of Molecular Pathology, University Hospital, Verona, Italy
| | - Alessia Finotti
- Department of Life Sciences and Biotechnology, Section of Biochemistry and Molecular Biology, University of Ferrara, Ferrara, Italy
| | - Claudio Ghimenton
- Section of Pathology and Histology, University Hospital, Verona, Italy
| | - Albino Eccher
- Section of Pathology and Histology, University Hospital, Verona, Italy
| | - Maria Dechecchi
- Department of Pathology and Diagnostics, Laboratory of Molecular Pathology, University Hospital, Verona, Italy
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, Laboratory of Molecular Pathology, University Hospital, Verona, Italy.,Section of Pathology and Histology, University Hospital, Verona, Italy.,Applied Research on Cancer Network (ARC-NET), University and Hospital Trust, Verona, Italy
| | - Brian Hirshman
- Center for Theoretical and Applied Neuro-oncology, Moores Cancer Center, Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Clark Chen
- Center for Theoretical and Applied Neuro-oncology, Moores Cancer Center, Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Manuela Ferracin
- Department of Morphology, Surgery and Experimental Medicine and Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Massimo Negrini
- Department of Morphology, Surgery and Experimental Medicine and Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Roberto Gambari
- Department of Life Sciences and Biotechnology, Section of Biochemistry and Molecular Biology, University of Ferrara, Ferrara, Italy
| | - Giulio Cabrini
- Department of Pathology and Diagnostics, Laboratory of Molecular Pathology, University Hospital, Verona, Italy.,Section of Pathology and Histology, University Hospital, Verona, Italy
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Li J, Kaneda M, Wang J, Akers J, Ramakrishnan V, Amirfakhri S, Hirshman B, Furnari F, Jiang T, Carter B, Glass C, Ren B, Varner J, Chen C. DRES-15. IL11 SECRETION BY GLIOBLASTOMA ASSOCIATED MICROGLIA DEFINE A STAT3-MYC SIGNALING AXIS THAT IS SUPPRESSED IN “EXCEPTIONAL RESPONDERS”. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Joshi R, Hirshman B, Ali MA, Carroll K, Wilson B, Proudfoot J, Serizawa T, Yamamoto M, Nagano O, Aiyama H, Carter B, Chen C. CMET-45. USING CUMULATIVE INTRACRANIAL TUMOR VOLUME AS A PROGNOSTIC FACTOR IN THE GI-SPECIFIC GRADED PROGNOSTIC ASSESSMENT (GPA) MODEL. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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13
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Carroll KT, Hirshman B, Ali MA, Alattar AA, Brandel MG, Lochte B, Lanman T, Carter B, Chen CC. Management and Survival Patterns of Patients with Gliomatosis Cerebri: A SEER-Based Analysis. World Neurosurg 2017; 103:186-193. [DOI: 10.1016/j.wneu.2017.03.103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/20/2017] [Accepted: 03/21/2017] [Indexed: 01/27/2023]
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14
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Wali AR, Santiago-Dieppa DR, Cheung V, Steinberg J, Hirshman B, Abraham P, Porras K, Brandel M, Jurf J, Botts E, Pannell S, Khalessi A. Abstract 050: Improvements in Door to Groin Puncture Time for Surgical Stroke After Quality Protocol Interventions at the University of California, San Diego. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Delays in door to groin puncture time (DGPT) for patients with ischemic stroke caused by acute large vessel occlusion (LVO) correlate with worse clinical outcomes. Stroke centers aim to minimize DGPT to facilitate prompt intervention and limit ischemic brain injury. In this study, we present the results of a comprehensive quality assessment at the University of California, San Diego (UCSD). From 2015 to 2016, institutional implementation of a quality improvement protocol significantly reduced DGPT.
Materials and Methods:
Beginning July 2015, the UCSD interdisciplinary stroke team implemented a series of quality improvement measures to decrease DGPT, with a target of 90 minutes or less. After each case, areas of inefficiency were identified and changes were implemented based on direct feedback from neurointerventional physicians and ancillary staff. Changes included: 1) creation of a pager group notification system to activate the entire neurointerventional team simultaneously, 2) consistently involving anesthesia with each neurointervention, 3) streamlining communication between the vascular neurology and neurointervention teams, and 4) structuring parallel workflows to enhance mobilization speed. R statistical software was utilized to compare DGPT before and after implementation of these process improvements. Patients were divided into three groups based on the date of their intervention as follows: 23 patients treated from July-December 2015, 24 patients treated from January-July 2016, and 14 patients treated from July 2016-December 2016. A multivariable univariate binary logistic regression model was constructed to capture predictors of compliance with our target DGPT (<90 min). Variables analyzed included: date of intervention, mode of patient admission (i.e. transfer, direct admit from ED, inpatient), hospital location, age, and gender.
Results:
61 patients underwent mechanical thrombectomy for treatment of acute LVO from July 2015 to December 2016. In our analysis, date of intervention—as a proxy for implementation of process improvement protocols—and mode of admission were predictive of compliance with target DGPT. Patients who were treated from July 2016 to December 2016—after full implementation of process improvements— were 9.5 times more likely to meet or exceed the target DGPT compared to patients treated July 2015 to December 2015 (p=0.01). Additionally, arrival via transfer from an outside hospital was determined to be an independent predictor of meeting DGPT goals. (p=0.02).
Conclusion:
UCSD’s quality improvement process effected dramatic, statistically significant improvement in DGPT. This analysis demonstrates the utility of a formal quality improvement system at a large, academic comprehensive stroke center.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Julie Jurf
- Univ of California, San Diego, La Jolla, CA
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15
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Tringale KR, Wilson BR, Hirshman B, Zhou T, Folsom D, Norman MA, Grant I, Chen CC, Carter BS. Psychiatric Disease Preceding Intracranial Tumor Diagnosis: Investigating the Association. Prim Care Companion CNS Disord 2016; 18. [PMID: 28002663 DOI: 10.4088/pcc.16m02028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022] Open
Abstract
Objective Here, we examine rates of intracranial tumor diagnoses in patients with and without comorbid psychiatric diagnoses to better understand how psychiatric disease may alter risk profiles for brain tumor diagnosis. Methods We used a longitudinal version of the California Office of Statewide Health Planning and Development (OSHPD) database, which includes all inpatient admissions in California from 1995 to 2010. We examined patients with confirmed hospital admissions from 1997 to 2004. Patients with an intracranial tumor or psychiatric diagnosis on their first hospital admission were excluded. The primary outcome of interest was the diagnosis of intracranial tumor on any subsequent hospitalization within 5 years. Risk of tumor diagnosis was determined via Cox proportional hazard models adjusted for age, gender, race/ethnicity, and comorbidity burden. Subset analyses were performed for various tumor types. Results The risk for diagnosis of an intracranial tumor within 5 years, as determined by the hazard ratio, was 1.61 (95% CI, 1.28-2.04) for bipolar, 1.59 (95% CI, 1.41-1.72) for anxious, and 1.34 (95% CI, 1.25-1.43) for depressed cohorts relative to controls. More specifically, the risk for diagnosis of a primary benign neoplasm was elevated in depressed patients, while the risk for diagnosis of a meningioma was elevated in depressed, anxious, and bipolar disorder patients. Conclusions Patients admitted with certain psychiatric diagnoses appear more likely to be readmitted within 5 years with specific types of intracranial tumor diagnoses. The association between certain psychiatric diagnoses and subsequent brain tumor diagnosis most likely reflects the long-held belief that slow-growing tumors may first present as psychiatric symptoms before being diagnosed. Primary care physicians should consider the possibility of an underlying intracranial tumor in patients with new psychiatric diagnoses.
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Affiliation(s)
- Kathryn R Tringale
- School of Medicine, University of California, San Diego, California, USA
| | - Bayard R Wilson
- School of Medicine, University of California, San Diego, California, USA
| | - Brian Hirshman
- Department of Neurosurgery, University of California, San Diego, California, USA
| | - Tianzan Zhou
- School of Medicine, University of California, San Diego, California, USA
| | - David Folsom
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Marc A Norman
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Igor Grant
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Clark C Chen
- Department of Neurosurgery, University of California, San Diego, California, USA
| | - Bob S Carter
- Department of Neurosurgery, University of California, San Diego, CA. .,Department of Neurosurgery, University of California, San Diego, California, USA
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16
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Wilson B, Curtis E, Hirshman B, Oygar A, Chen K, Gabel BC, Vaida F, Allison DW, Ciacci JD. Lateral mass screw stimulation thresholds in posterior cervical instrumentation surgery: a predictor of medial deviation. J Neurosurg Spine 2016; 26:346-352. [PMID: 27935447 DOI: 10.3171/2016.8.spine16580] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Normative data exists for stimulus-evoked pedicle screw electromyography (EMG) current thresholds in the lumbar spine, and is routinely referenced during spine surgeries to detect a screw breach, prevent injury of neural elements, and ensure the most biomechanically sound instrumentation construct. To date, similar normative data for cervical lateral mass screws is limited, thus the utility of lateral mass screw testing remains unclear. To address this disparity, in this study the authors describe cumulative lateral mass screw stimulation threshold data in patients undergoing posterior cervical instrumentation with lateral mass screws. These data are correlated with screw placement on postoperative imaging, and a novel correlation is discovered with direct clinical implications. METHODS Using a ball-tip probe, 154 lateral mass screws in 21 patients were electrically tested intraoperatively. In each case, for each screw, the lowest (or threshold) current at which the first polyphasic stimulus-evoked EMG response was reproducibly observed by a neurophysiologist was recorded. All patients underwent postoperative CT. Screw position within the lateral mass was first measured in the axial and sagittal planes for each lateral mass screw using the CT images. Screw placement was also evaluated by 2 independent physicians, blinded to current threshold data, on a binary scale of acceptability. The predictive capacity of screw EMG threshold data was evaluated via multivariable regression analyses and receiver operating characteristic (ROC) analyses. Predictive capacity was examined with respect to screw position within the lateral mass, as well as screw acceptability. RESULTS Lateral mass screw EMG thresholds did not appear to differ significantly for screws considered "acceptable" versus "unacceptable" according to the radiographic criteria. Accordingly, ROC analysis confirmed that EMG current threshold data were of minimal utility in predicting screw radiographic acceptability. However, EMG threshold was significantly predictive of screw medial distance from the spinal canal. A screw stimulating below 7.5 mA correctly identified a screw as being within 2 mm of the spinal canal with 75% sensitivity and 92% specificity (positive predictive value 20%, negative predictive value 99.3%), independent of its distance relative to other lateral mass landmarks. EMG current threshold was not significantly predictive of screw deviation in the superior or inferior directions, and was inversely predictive of screw deviations in the lateral direction. CONCLUSIONS In the context of uncertainty regarding the utility of cervical lateral mass EMG current threshold data, this study found that EMG current thresholds correspond significantly, and exclusively, with screw distance from the spinal canal. This association appears independent of other criteria for screw misplacement. As such, the authors recommend that EMG current thresholds be referenced in the case of a suspected medial breach as an effective means to rule out screw placement too medial to the spinal canal.
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Affiliation(s)
| | | | | | | | | | | | - Florin Vaida
- Department of Family Medicine and Public Health, Division of Biostatistics and Bio-informatics, and
| | - David W Allison
- Department of Interventional Neurophysiology, University of California, San Diego, California
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Hirshman B, Jones L, Tang J, Ali MA, Proudfoot J, Carley K, Carter B, Chen C. SURG-41. “JOURNAL BIAS” IN NEURO-ONCOLOGY: AN ANALYSIS OF THE SURGICAL HIGH GRADE GLIOMA LITERATURE. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now212.839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chen C, Hirshman B, Wilson B, Amaan M, Proudfoot J, Koiso T, Nagano O, Serizawa T, Yamamoto M. RTHP-25. SUPERIOR PROGNOSTIC VALUE OF CUMULATIVE INTRACRANIAL TUMOR VOLUME (CITV) RELATIVE TO LARGEST INTRACRANIAL TUMOR VOLUME (LITV) FOR STEREOTACTIC RADIOSURGERY TREATED BRAIN METASTASIS PATIENTS. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now212.751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hirshman B, Wilson B, Ali MA, Proudfoot J, Koiso T, Nagano O, Serizawa T, Yamamoto M, Carter B, Chen C. BMET-36. OPTIMAL RADIOSURGERY DOSE FOR TREATMENT OF MELANOMA AND RENAL CELL CARCINOMA METASTASES. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now212.136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wilson B, Hirshman B, Chen C. SURG-11. PERSONAL PREFERENCES FOR GROSS TOTAL RESECTION OF GLIOBLASTOMA: A PILOT STUDY. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now212.812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Dong X, Noorbakhsh A, Hirshman B, Zhou T, Tang J, Chang D, Carter B, Chen C. EPID-09IMPROVED SURVIVAL OF LOW-GRADE GLIOMA PATIENTS (1999-2010) DESPITE DECREASED UTILIZATION OF RADIATION THERAPY: A SEER-BASED ANALYSIS. Neuro Oncol 2015. [DOI: 10.1093/neuonc/nov213.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Dong X, Hirshman B, Padwal J, Proudfoot J, Chen C. SURG-08SUPERIOR EFFICACY OF GROSS TOTAL RESECTION IN ANAPLASTIC ASTROCYTOMA PATIENTS RELATIVE TO GLIOBLASTOMA PATIENTS. Neuro Oncol 2015. [DOI: 10.1093/neuonc/nov235.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hatefi D, Hirshman B, Leys D, Lejeune JP, Marshall L, Carter BS, Kasper E, Chen CC. Hemicraniectomy in the management of malignant middle cerebral artery infarction: Lessons from randomized, controlled trials. Surg Neurol Int 2014; 5:72. [PMID: 24991475 PMCID: PMC4078455 DOI: 10.4103/2152-7806.132589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 03/06/2014] [Indexed: 11/27/2022] Open
Affiliation(s)
- Dustin Hatefi
- Division of Neurosurgery, University of California, San Diego, CA
| | - Brian Hirshman
- Division of Neurosurgery, University of California, San Diego, CA
| | - Didier Leys
- Department of Neurology and Neurosurgery, University of Lille North of France, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurology and Neurosurgery, University of Lille North of France, Lille, France
| | | | - Bob S Carter
- Division of Neurosurgery, University of California, San Diego, CA
| | - Ekkehard Kasper
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Clark C Chen
- Division of Neurosurgery, University of California, San Diego, CA
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