Northwestern Memorial Hospital (NMH) is a nationally ranked academic medical center located on Northwestern University’s Chicago campus in Streeterville, Chicago, Illinois. It is the flagship campus for Northwestern Medicine and the primary teaching hospital for the Feinberg School of Medicine at Northwestern University. Affiliated institutions also located on campus include the Ann & Robert H. Lurie Children's Hospital with Level I pediatric trauma care and the Shirley Ryan AbilityLab, a leader in physical medicine and rehabilitation.In 2020, U.S. News and World Report ranked Northwestern Memorial as the top hospital in both Chicago and Illinois for the ninth consecutive year and #10 in the nation for the second year. In the same report, Northwestern Memorial is nationally ranked in 11 adult specialties including #5 in Neurology & Neurosurgery.S.
The recognition of autoimmune and paraneoplastic antibodies in neurological disease has expanded substantially in recent years. Acquired nystagmus may serve as an early or presenting manifestation, particularly in rapidly progressive syndromes. We review a practical approach to the evaluation of patients presenting with new-onset nystagmus or abnormal saccadic oscillations. Distinct nystagmus phenotypes have been linked to specific antibody-mediated syndromes, while in others considerable overlap exists. Opsoclonus is increasingly recognized as a nonspecific finding across multiple etiologies. Additionally, the acute vestibular syndrome may represent an early manifestation of antibody-mediated disease (e.g., GQ1b, KLHL11). When an autoantibody etiology is suspected, early empiric immunotherapy and a thorough evaluation for underlying malignancy are warranted. In this article review, we summarize the types of acquired nystagmus, outline a comprehensive workup and initial treatment approach for suspected autoimmune or paraneoplastic etiologies, and we discuss how the nystagmus semiology may inform localization, guide evaluation, and prioritize targeted antibody testing.
Background: Noncommunicable diseases (NCDs) have become the leading cause of mortality worldwide. NCDs account for 89% of all deaths in the United States and cost the US economy more than US $47 trillion in direct and indirect expenses. NCDs also account for the main cause of disability worldwide, and the incidence is increasing. The leading NCDs include diabetes, cancer, cardiovascular disease, chronic respiratory disease, and mental health conditions. Outside of aging, NCDs are caused by modifiable behavioral risk factors that include smoking, drug and alcohol abuse, unhealthy diet, obesity, and inadequate physical activity, and treatment must be directed to all of these domains. We hypothesize that a digital twin concept can be used to personalize treatment regimens through analysis of data that allows for artificial intelligence-based decision making. Objective: This study aims to present a methodology to validate this concept, which would provide a new clinical approach toward addressing the leading cause of disability and mortality worldwide today. Methods: This study will use delta scores between treatment arms to ascertain whether that distribution was normal for each of the study variables. Parametric (eg, analysis of covariance) or nonparametric analyses will be used to examine the variables to determine the impact of digital twin efficacy over normal treatment paradigms. Results: Recruitment of participants is expected to begin 6 months after study funding has been awarded and the needed approvals have been obtained. The expected results will show that digital twin modeling using the biopsychosocial characteristics of each participant will be statistically significant, supporting using this approach for personalized medical care. Conclusions: This study can help to identify significant clinical characteristics to help mitigate the impact of NCDs through biopsychosocial treatment paradigms. This paper proposes a statistical framework to evaluate the validity of the platform's modeling in support of clinical decision making.
Obesity is widely recognized as a risk factor for poor outcomes following ventral hernia repair. This belief has led many surgeons to implement arbitrary body mass index (BMI) cutoffs, typically 35–40 kg/m2, before offering elective hernia repair. These practices are based on low-quality evidence and create significant challenges for patients with symptomatic hernias who lack access to metabolic and bariatric surgery or obesity medications. We aim to compare medical weight loss followed by surgery versus upfront surgery in patients with severe obesity undergoing ventral hernia repair. This is a registry-based, parallel, randomized controlled trial with 1:1 allocation. A total of 258 patients with a BMI 40–55 kg/m2 who are planning to undergo open retromuscular ventral hernia repair are randomized to a six-month preoperative medical weight loss program followed by surgery or upfront surgery. The medical weight loss program is conducted by a nurse practitioner trained in obesity medicine. The primary hypothesis is that abdominal wall-specific quality of life, as measured by Hernia-Related Quality-of-Life Survey (HerQLes) summary scores at one year, for the upfront abdominal wall reconstruction intervention will be non-inferior compared to a preoperative medical weight loss program followed by surgery. Secondary outcomes include hernia recurrence rates at one-year, wound morbidity at 30 days and one year, and rates of emergency hernia repair, readmissions, complications, and reoperations between groups. Patient-reported outcomes include quality of life and pain scores at baseline, 30 days, and after completing the standard medical weight loss program. Weight-related outcomes include changes in weight from enrollment through one-year follow-up, rate of achievement of weight loss goals, and the association of weight loss and program completion on postoperative outcomes. Lastly, we will evaluate cost-effectiveness using quality-adjusted life years and incremental cost-effectiveness ratios. Preoperative weight loss offers potential benefits for patients with obesity undergoing hernia repair including decreased wound morbidity, reduced technical difficulty, and potentially lower recurrence rates. However, disadvantages include prolonged diminished quality of life, risk of emergent hernia repair during the weight loss period, limited access to effective weight loss interventions, and challenges with adherence to weight loss protocols and long-term weight maintenance. This randomized controlled trial will provide high-quality evidence on whether intensive preoperative medical weight loss improves outcomes compared to immediate surgical repair in patients with severe obesity, helping to establish evidence-based guidelines for this challenging patient population. NCT05925959 (registered June 22, 2023).
BACKGROUND:A carotid web (CaW) is a non-atheromatous, shelf-like intraluminal projection, commonly affecting the internal carotid artery. It can be associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. The natural history of CaW is not well-established. Several studies have reported on outcomes after interventional and medical therapy with variable results. OBJECTIVE:To synthesize the literature and report the clinical characteristics and management outcomes of patients with CaWs. METHODS:A systematic literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS:33 studies comprising 737 patients (mean age 50.2 years, female 59.4%, African American 65%) with 835 CaWs were included. The majority of the CaWs were symptomatic (72.9%) with a mean National Institutes of Health Stroke Scale (NIHSS) admission score of 7.5. Atherosclerotic plaques and intramural thrombi were each present in 33% of patients. The classic atherosclerotic and stroke risk factors were prevalent as follows: hypertension 37.8%, diabetes 14.6%, smoking 21.7%, dyslipidemia 16.7%. In total, treatment outcomes were available for 376 patients with 448 symptomatic CaWs (227 medical, 221 interventional). Medical therapy consisted of antiplatelet or anticoagulation medications, while interventional treatment included carotid artery stenting (CAS), carotid endarterectomy (CEA), and internal carotid artery resection and primary anastomosis (ICRA). The interventional group was associated with a significantly lower risk of recurrent ischemic events compared with the medical group (interventional 0%, medical 36.1%; OR 14.18, 95% CI 3.17 to 63.46, P=0.001) over a mean follow-up of 21.2 months. The odds ratio of cerebral ischemic event recurrence was correlated with the need for thrombectomy at the first event and history of dyslipidemia. CONCLUSIONS:Most CaWs were found during stroke work-up. Prevention of secondary ischemic events was superior in the interventional management group (CAS, CEA, ICRA) compared with the medical management group.
