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BACKGROUND: Oral anticoagulation is becoming more common with the aging population, which raises concern for the risk of invasive procedures that can cause bleeding, such as chest tube placement (thoracostomy). With the increase in CT imaging, more pneumothoraces and hemothoraces are being identified. The relative risk of thoracostomy in the presence of anticoagulation is not well-established. The objective of this study was to determine whether pre-injury anticoagulation affects the relative risk of tube thoracostomy following significant chest trauma. METHODS: This retrospective cohort study used data from the 2019 American College of Surgeons-Trauma Quality Program (ACS-TQP) database using R version 4.2.2. Data from the database was filtered based on inclusion and exclusion criteria. Outcomes were then assessed with the population of interest. Demographics, vitals, comorbidities, and injury parameters were also collected for each patient. This study included all adult patients (≥18 years) presenting with traumatic hemothorax, pneumothorax, or hemopneumothorax. Patients with missing data in demographics, vitals, comorbidities, injury parameters, or outcomes, as well as those with no signs of life upon arrival, were excluded from the study. Patients were stratified into groups based on whether they had pre-injury anticoagulation and whether they had a chest tube placed in the hospital. The primary outcome was mortality, and the secondary outcome was hospital length of stay (LOS). Logistic and standard regressions were used by a statistician to control for age, sex, and Injury Severity Score (ISS). RESULTS: Our study population included 72,385 patients (4250 with pre-injury anticoagulation and 68,135 without pre-injury anticoagulation). Pre-injury anticoagulation and thoracostomy were each independently associated with increased mortality and LOS. However, there was a non-significant interaction term between pre-injury anticoagulation and thoracostomy for both outcomes, indicating that their combined effects on mortality and LOS did not differ significantly from the sum of their individual effects. CONCLUSION: This study suggests that both pre-injury anticoagulation and thoracostomy are risk factors for mortality and increased LOS in adult patients presenting with hemothorax, pneumothorax, or hemopneumothorax, but they do not interact with each other. We recommend further study of this phenomenon to potentially improve clinical guidelines. LEVEL OF EVIDENCE: Therapeutic, Level III.

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BACKGROUND: Deep Brain Stimulation (DBS) of the subthalamic nucleus or globus pallidus internus is used to treat the motor symptoms of Parkinson's disease. The former can worsen impulsive and compulsive behaviors after controlling for the reduction of dopaminergic medications. However, the effect of pallidal DBS on such behaviors in PD patients is less clear. OBJECTIVE/HYPOTHESIS: We hypothesized that greater stimulation spread to the pallidum with prefrontal connectivity would reduce motor impulsivity. METHODS: Seven Parkinson's patients with stable globus pallidus internus DBS settings for 3 months, disease duration of 13 ± 1.3 years, and Montreal Cognitive Assessment of 26.8 ± 1.1 each had two stimulation settings defined based on reconstructions of lead placement and volume of tissue activation targeting either a dorsal or ventral position along the DBS electrode but still within the globus pallidus internus. Subjects performed a stop signal reaction time task with the DBS turned off vs. on in each of the defined stimulation settings, which was correlated with the degree of stimulation effect on pallidal subregions. RESULTS: A shorter distance between the volume of tissue activation and the right prefrontally-connected GPi correlated with less impulsivity on the stop signal reaction time task (r = 0.69, p < 0.05). Greater volume of tissue activation overlap with the non-prefrontally-connected globus pallidus internus was associated with increased impulsivity. CONCLUSION: These data can be leveraged to optimize DBS programming in PD patients with problematic impulsivity or in other disorders involving impulsive behaviors such as substance use disorders.

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BACKGROUND: Radiographic characterization of Chiari malformation (CM) has historically focused on caudal tonsillar herniation (CH) below the foramen magnum. Previously, we published evidence linking ventral tonsillar herniation (VH) and medullary symptoms in very young children. We sought to extend that investigation by studying the radiographic and clinical significance of VH in adults diagnosed with CM. METHODS: We retrospectively reviewed adults with cerebellar ectopia who underwent posterior fossa decompression with or without duraplasty (PFD/D) at our institution. VH was defined as tonsils crossing a line bisecting the caudal medulla at the level of the foramen magnum on axial MRI. Degree of VH was measured as distance between this bisecting line and the ventral tip of the herniated tonsil. Dorsal brainstem compression was qualitatively determined by assessing for obliteration of CSF space between the dorsal brainstem and the tonsils. RESULTS: Out of 89 cases reviewed, 54 had some degree of VH. Compared with those without VH, the VH group was significantly older in age and more likely to also present with dorsal brainstem compression and headaches. No correlation was observed between degrees of CH and VH in the VH group. The degree of VH significantly decreased 3 months after PFD/D. CONCLUSIONS: VH is relatively common in CM patients and might be an important independent radiographic metric to evaluate and consider as part of the decision-making process, especially in those presenting with Chiari-like symptomatology referable to the medulla but who do not meet the traditional criteria of cerebellar ectopia greater than 5 mm.

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