Neurosurgery
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Glioma continues to be a challenging disease process, making up the most common tumor type within the pediatric population. While low-grade gliomas are typically amenable to surgical resection, higher grade gliomas often require additional radiotherapy in conjunction with adjuvant chemotherapy. Molecular profiling of these lesions has led to the development of various pharmacologic and immunologic agents, although these modalities are not without great systemic toxicity. ⋯ Initially discovered by chance in the early 20th century, virotherapy has emerged as a viable treatment option. With promising results based on preclinical studies, the authors review several oncolytic viruses, with a focus on molecular mechanism and efficacy of these viruses in tumor cell lines and murine models. In addition, current phase I clinical trials evaluating oncolytic virotherapy in the treatment of pediatric glioma are summarized.
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In both academic and private practice, noncompete clauses are common in many neurological surgery contracts. Noncompete agreements vary, depending on various factors, including the surgeon's subspecialty, location, and business-related considerations. Each individual state's law on contracts determines the extent to which noncompete clauses are enforceable. ⋯ It is imperative that individuals understand the content of any noncompete clauses in their contract, as well the climate of the state in which they practice. The state's approach determines whether any part or all of the noncompete agreement is enforceable. A review by the Workforce Committee and the Medico-legal Committee of the Council of State Neurosurgical Societies (CSNS) provides explanation of the common elements in restrictive covenants or noncompete clauses and reviews the enforceability of these clauses.
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Modern medical management of metastatic renal cell carcinoma (RCC) includes therapies targeting tyrosine kinases, growth pathways (mammalian target of rapamycin (mTOR)), and immune checkpoints. ⋯ Postoperative outcomes and palliation of symptoms for metastatic RCC without targeted therapies in this cohort are similar to those reported in earlier series prior to the adoption of these systemic therapies. We observed a significantly longer OS among patients who received modern systemic therapies postoperatively. These findings have implications for the preoperative evaluation of patients with systemic disease who may have been deemed poor surgical candidates prior to the availability of these systemic therapies.
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Pre- and postoperative cognitive deficits have repeatedly been demonstrated in patients with glioblastoma (GBM). ⋯ We demonstrated preoperative cognitive risk factors that enable the identification of GBM patients who are at risk for cognitive impairment 3 mo after surgery. This information can help to inform patients and clinicians at an early stage, and emphasizes the importance of recognizing, assessing, and actively dealing with cognitive functioning in the clinical management of GBM patients.
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As spine surgery becomes increasingly common in the elderly, frailty has been used to risk stratify these patients. The Hospital Frailty Risk Score (HFRS) is a novel method of assessing frailty using International Classification of Diseases, Tenth Revision (ICD-10) codes. However, HFRS utility has not been evaluated in spinal surgery. ⋯ HFRS is a better predictor of length of stay (LOS), ICU stays, and nonhome discharges than readmission and may improve on modified frailty index in predicting LOS. Since ICU stays and nonhome discharges are the main drivers of cost variability in spine surgery, HFRS may be a valuable tool for cost prediction in this specialty.