Faculty Bibliography

The use of cannabis among college students is increasing. Cannabis abuse has been proposed to be associated with personality dimensions. However, there are currently no known studies on the relationship of temperament traits and recreational cannabis use among college students. This is a cross-sectional study that investigated 328 students at a Podiatric Medical College. We evaluated the association between temperament and recreational cannabis use by the students. Temperament was investigated using the Memphis, Pisa, Paris and San Diego Auto- Questionnaire (TEMPS-A (short version)). Additionally, we assessed demographics variables and perceived stress in the context of cannabis use, and analyzed the findings using logistic regression. The prevalence of recreational cannabis use was 8.45%. Recreational cannabis use among these students was highly associated with irritable and cyclothymic temperament traits. There was no association between recreational cannabis use and perceived stress, and demographic variables or other substance use. Furthermore, logistic regression analysis indicated that higher scores in cyclothymic or irritable temperament traits are significant predictors for recreational cannabis use. Our study has identified key temperament traits, with a strong association with recreational use of cannabis of the studied student population. Our findings are useful in designing screening and educational strategies directed towards increasing the wellbeing of medical students.

PURPOSE OF REVIEW/OBJECTIVE:Our understanding of the genetic and epigenetic alterations in meningioma and the underlying tumor biology of meningioma has significantly changed over the past decade and resulted in revision of prognostically relevant meningioma subclasses within and beyond the WHO classification of CNS tumors. RECENT FINDINGS/RESULTS:The 2016 WHO classification of CNS tumors recognizes WHO grade I, II, and III based on histopathological features. Recent work has identified genetic alterations with prognostic implications, including mutations of the TERT promoter, loss of function of the DMD gene, and inactivation of the tumor suppressor BAP-1. Studies of DNA methylation patterns in meningiomas have resulted in a novel and prognostically relevant meningioma subclassification schema. There have been major advances in our understanding of prognostically relevant genetic and epigenetic changes in meningioma which will hopefully allow for improvement in clinical trial design and the development of more effective therapies for meningioma.

BACKGROUND:The supraorbital craniotomy (SOC) is classically performed through a skin incision in the patient's eyebrow. A variant with a skin incision in the patient's eyelid has become increasingly popular in recent years. OBJECTIVE:To compare the transpalpebral and the transciliary variants of the SOC with regard to their potential role in aneurysm surgery. METHODS:We carried out cadaveric dissections and virtual craniotomies on computerized tomography datasets. The skin incision, the craniotomy location and size, the working angles, and the achievable exposure of neurovascular structures were assessed and compared for both variants of the SOC. RESULTS:The skin incision measured 4 cm for the transpalpebral and 3 cm for the transciliary variant. The skin could be retracted 1.5 cm upward from the lower edge of the orbital rim with the transpalpebral and 2.5 cm upward with the transciliary variant. The craniotomy size was 2.5 × 1.5 cm for both variants, given that the transpalpebral variant included an orbital osteotomy. The bony opening in the transpalpebral variant was 1 cm more caudal; this restricted the craniocaudal working angles and, thereby, limited the achievable exposure of neurovascular structures in the paraclinoid area and along the sphenoid ridge. CONCLUSION/CONCLUSIONS:If the orbital rim and the anterior aspect of the orbital roof are removed, then the transpalpebral variant of the SOC enables a bony opening that is just as large as that of the transciliary variant. Nonetheless, the more caudal location of the bony opening alters the available working angles and may impede exposure of key structures during aneurysm surgery.

Importance/UNASSIGNED:Positron emission tomography (PET) may increase the diagnostic accuracy and confirm the underlying neuropathologic changes of Alzheimer disease (AD). Objective/UNASSIGNED:To determine the accuracy of antemortem [18F]flortaucipir PET images for predicting the presence of AD-type tau pathology at autopsy. Design, Setting, and Participants/UNASSIGNED:This diagnostic study (A16 primary cohort) was conducted from October 2015 to June 2018 at 28 study sites (27 in US sites and 1 in Australia). Individuals with a terminal illness who were older than 50 years and had a projected life expectancy of less than 6 months were enrolled. All participants underwent [18F]flortaucipir PET imaging, and scans were interpreted by 5 independent nuclear medicine physicians or radiologists. Supplemental autopsy [18F]flortaucipir images and pathological samples were also collected from 16 historically collected cases. A second study (FR01 validation study) was conducted from March 26 to April 26, 2019, in which 5 new readers assessed the original PET images for comparison to autopsy. Main Outcomes and Measures/UNASSIGNED:[18F]flortaucipir PET images were visually assessed and compared with immunohistochemical tau pathology. An AD tau pattern of flortaucipir retention was assessed for correspondence with a postmortem B3-level (Braak stage V or VI) pathological pattern of tau accumulation and to the presence of amyloid-β plaques sufficient to meet the criteria for high levels of AD neuropathological change. Success was defined as having at least 3 of the 5 readers above the lower bounds of the 95% CI for both sensitivity and specificity of 50% or greater. Results/UNASSIGNED:A total of 156 patients were enrolled in the A16 study and underwent [18F]flortaucipir PET imaging. Of these, 73 died during the study, and valid autopsies were performed for 67 of these patients. Three autopsies were evaluated as test cases and removed from the primary cohort (n = 64). Of the 64 primary cohort patients, 34 (53%) were women and 62 (97%) were white; mean (SD) age was 82.5 (9.6) years; and 49 (77%) had dementia, 1 (2%) had mild cognitive impairment, and 14 (22%) had normal cognition. Prespecified success criteria were met for the A16 primary cohort. The flortaucipir PET scans predicted a B3 level of tau pathology, with sensitivity ranging from 92.3% (95% CI, 79.7%-97.3%) to 100.0% (95% CI, 91.0%-100.0%) and specificity ranging from 52.0% (95% CI, 33.5%-70.0%) to 92.0% (95% CI, 75.0%-97.8%). A high level of AD neuropathological change was predicted with sensitivity of 94.7% (95% CI, 82.7%-98.5%) to 100.0% (95% CI, 90.8%-100.0%) and specificity of 50.0% (95% CI, 32.1%-67.9%) to 92.3% (95% CI, 75.9%-97.9%). The FR01 validation study also met prespecified success criteria. Addition of the supplemental autopsy data set and 3 test cases, which comprised a total of 82 patients and autopsies for both the A16 and FR01 studies, resulted in improved specificity and comparable overall accuracy. Among the 156 enrolled participants, 14 (9%) experienced at least 1 treatment-emergent adverse event. Conclusions and Relevance/UNASSIGNED:This study's findings suggest that PET imaging with [18F]flortaucipir could be used to identify the density and distribution of AD-type tau pathology and the presence of high levels of AD neuropathological change, supporting a neuropathological diagnosis of AD.

Early-phase clinical trials using oral inhibitors of MEK, the mitogen-activated protein kinase kinase, have demonstrated benefit for patients with neurofibromatosis type 1 (NF1)-associated tumors, particularly progressive low-grade gliomas and plexiform neurofibromas. Given this potential of MEK inhibition as an effective medical therapy, the use of targeted agents in the NF1 population is likely to increase substantially. For clinicians with limited experience prescribing MEK inhibitors, concern about managing these treatments may be a barrier to use. In this manuscript, the Clinical Care Advisory Board of the Children's Tumor Foundation reviews the published experience with MEK inhibitors in NF1 and outlines recommendations for side-effect management, as well as monitoring guidelines. These recommendations can serve as a beginning framework for NF providers seeking to provide the most effective treatments for their patients. IMPLICATIONS FOR PRACTICE: Neurofibromatosis type 1 (NF1) clinical care is on the cusp of a transformative shift. With the success of recent clinical trials using MEK inhibitors, an increasing number of NF1 patients are being treated with MEK inhibitors for both plexiform neurofibromas and low-grade gliomas. The use of MEK inhibitors is likely to increase substantially with the expected upcoming approval of selumetinib for a specific indication for treatment of plexiform neurofibromas in NF1. Given these changes, the Clinical Care Advisory Board of the Children's Tumor Foundation has identified a need within the NF1 clinical community for guidance for the safe and effective use of MEK inhibitors for NF1-related tumors. This article provides a review of the published experience of MEK inhibitors in NF1 and provides recommendations for monitoring and management of side effects.

BACKGROUND:Many headache smartphone applications (apps) are commercially available. A Modified Delphi Study aimed to determine specialists' expectations of what a headache app should entail but consumer expectations of headache apps have not been evaluated extensively. OBJECTIVE:To evaluate publicly available reviews of headache apps to understand app features that motivate the consumers to use apps. METHODS:The Google Play and Apple App Stores were systematically searched for headache/migraine diary apps with 10+ consumer reviews. A maximum of 300 "Most Helpful" reviews for each app were extracted. Four coders coded reviews and resolved discrepancies. Themes and subthemes were created based on codes used 5+ times. RESULTS:About 15 apps met the study criteria (9 Android, 6 IOS). 945 reviews were coded. Four themes emerged: (1) App allows users to track headache characteristics, potential triggers, and treatments; (2) App usability; (3) Personalization and features to assess trends in data are key motivators for app use; (4) Ease with exportation and viewing data is critical. DISCUSSION/CONCLUSIONS:A user-centered design with the ability to (1) customize key features including headache characteristics, potential triggers, and treatments, (2) assess trends in data, and (3) view and export data would best optimize headache smartphone applications based on consumer preference.

INTRODUCTION:Embedded performance validity tests (PVTs) allow for continuous and economical validity assessment during neuropsychological evaluations; however, similar to their freestanding counterparts, a limitation of well-validated embedded PVTs is that the majority are memory-based. This study cross-validated several previously identified non-memory-based PVTs derived from language, processing speed, and executive functioning tests within a single mixed clinical neuropsychiatric sample with and without cognitive impairment. METHOD:This cross-sectional study included data from 124 clinical patients who underwent outpatient neuropsychological evaluation. Validity groups were determined by four independent criterion PVTs (failing ≤1 or ≥2), resulting in 98 valid (68% cognitively impaired) and 26 invalid performances. In total, 23 previously identified embedded PVTs derived from Verbal Fluency (VF), Trail Making Test (TMT), Stroop (SCWT), and Wisconsin Card Sorting Test (WCST) were examined. RESULTS:=.05-.22) with areas under the curve (AUCs) of.65-.81 and 19-54% sensitivity (≥89% specificity) at optimal cut-scores. When subdivided by impairment status, all PVTs except for WCST Failures to Maintain Set were significant (AUCs =.75-94) with 33-85% sensitivity (≥90% specificity) in the cognitively unimpaired group. Among the cognitively impaired group, most VF, TMT, and SCWT PVTs remained significant, albeit with decreased accuracy (AUCs =.65-.76) and sensitivities (19-54%) at optimal cut-scores, whereas all WCST PVTs were nonsignificant. Across groups, SCWT embedded PVTs evidenced the strongest psychometric properties. CONCLUSION:VF, TMT, and SCWT embedded PVTs generally demonstrated moderate accuracy for identifying invalid neuropsychological performance. However, performance on these non-memory-based PVTs from processing speed and executive functioning tests are not immune to the effects of cognitive impairment, such that alternate cut-scores (with reduced sensitivity if adequate specificity is maintained) are indicated in cases where the clinical history is consistent with cognitive impairment. In contrast, WCST indices generally had poor accuracy.

BACKGROUND AND PURPOSE/OBJECTIVE:Central retinal artery occlusion results in sudden, painless, usually permanent loss of vision in the affected eye. There is no proven, effective treatment to salvage visual acuity and a clear, unmet need for an effective therapy. In this work, we evaluated the efficacy of intravenous tissue-type plasminogen activator (IV alteplase) in a prospective cohort study and an updated systematic review and meta-analysis. METHODS:We enrolled consecutive patients with acute central retinal artery occlusion within 48 hours of symptoms onset and with a visual acuity of <20/200 from January 2009 until May 2019. The primary outcomes were safety and functional visual acuity recovery. We compared rates of visual recovery between those treated with alteplase within 4.5 hours of symptom onset to those who did not receive alteplase (including an analysis restricted to untreated patients presenting within the window for treatment). We incorporated these results into an updated systematic review and patient-level meta-analysis. RESULTS:=0.01). CONCLUSIONS:This study showed that the administration of intravenous alteplase within 4.5 hours of symptom onset is associated with a higher likelihood of a favorable visual outcome for acute central retinal artery occlusion. Our results strongly support proceeding to a randomized, placebo-controlled clinical trial.

Background: Fondaparinux is FDA-approved for prophylaxis of venous thromboembolism (VTE) in patients undergoing surgery as well as for the treatment of acute deep vein thrombosis and pulmonary embolism. Off-label, fondaparinux is used as an alternative to argatroban in the treatment of suspected or confirmed heparin-induced thrombocytopenia (HIT). The Antithrombotic/Hemostatic Stewardship Committee at NYU Langone Health (NYULH) provides guidance for the safe and effective use of fondaparinux, while assuring that an evidenced-based and cost-effective approach for utilization is maintained.
Aim(s): To evaluate the utilization of fondaparinux at NYULH and to assess guideline adherence, efficacy, safety, and cost avoidance.
Method(s): This was a retrospective review of adult patients who received fondaparinux between November 2016 and June 2019 at NYULH. The primary outcome was assessment of fondaparinux utilization based on the dosing guideline. Secondary outcomes included tolerability, safety, and cost-avoidance.
Result(s): Ninety-eight patients received fondaparinux, with the most frequent indications being suspected HIT (44%), VTE prophylaxis (23%), and continuation of home therapy (14%). Based on the NYULH fondaparinux dosing guideline, 97 (99%) patients were dosed appropriately. One patient (1%) received fondaparinux while on hemodialysis. Thromboembolic events occurred in 3 (3%) patients, major bleeding occurred in 4 (4%) patients and clinically relevant non-major bleeding occurred in 2 (2%) patients. In the 52 patients with suspected or confirmed HIT, the cost-avoidance of utilizing fondaparinux instead of argatroban was approximately $100,000.
Conclusion(s): The majority of fondaparinux utilization at NYULH is for suspected HIT, and dosing guidelines were followed in most cases. A low thromboembolic event rate with the use of fondaparinux was observed. The major and clinically relevant non-major bleeds experienced in six patients may be attributed to these patients' baseline high bleeding risk. Fondaparinux was a cost-effective alternative to argatroban in patients with suspected or confirmed HIT in this patient population. (Table Presented)