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Background: For adult patients with grade 1-3 gliomas, identifying patients with an indication for proton therapy (PT) can be challenging due to sparse evidence supporting its benefits. In this study, we aimed to ensure national consensus and develop a decision support tool to aid clinicians in identifying patients with grade 1-3 gliomas eligible for PT. Methods: Sixty-one historic patients referred for postoperative radiotherapy for glioma grade 1-3 were included in this study and had new photon therapy and PT plans calculated. These plans along with clinical parameters were presented to neurooncologists with experience in treating brain tumours. The patients were presented at three workshops (WSs), where each neurooncologist individually had to choose between photon and proton therapy. Important parameters were selected using cross validation. Multivariable logistic regression was used to predict the neurooncologists' treatment modality choice. Results: At the three WSs 23, 24 and 19 randomly selected patients were presented. Seventy-five percent of the neurooncologists agreed for 14 patients (61%), 16 patients (67%) and 15 patients (79%) at WS1, WS2 and WS3. Age at radiotherapy and difference in mean dose (ΔDmean) to the residual brain were significant predictors of the choice of treatment modality, p < 0.001. Model coefficients were: ßage = 0.07 per year (95% confidence interval [CI] = 0.05-0.09), and ßΔdose = -0.27 per Gy (95% CI=-0.36--0.18). Conclusion: Higher degree of agreement was reached. Age and ΔDmean to the residual brain significantly predicted the choice of radiation modality. We have developed a decision support model which may aid in the selection of patients with glioma grade 1-3 to PT.

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Introduction Complex distal humerus fractures pose significant challenges in orthopedic surgery, especially when traditional open reduction and internal fixation (ORIF) is not feasible. Primary elbow arthroplasty has emerged as an alternative treatment option for these fractures, but its application remains limited. This study aimed to evaluate the functional outcomes, patient selection criteria, and follow-up results of primary elbow arthroplasty in the management of complex distal humerus fractures. Methods A retrospective review was conducted on 15 patients who underwent primary elbow arthroplasty for Orthopaedic Trauma Association (OTA) type C distal humerus fractures between 2017 and 2023 at our institution. Inclusion criteria were patients aged 18 years or older who were offered either total elbow or hemiarthroplasty for acute complex distal humerus fracture. Data were collected from patient medical records, including demographic information, fracture classification, surgical details, and postoperative follow-up. Functional outcomes were assessed using the Oxford Elbow Score (OES) and Mayo Elbow Performance Score (MEPS). Complications were documented, and descriptive statistics were used to summarise the findings. Results The mean age of the patients was 71.8 years (IQR 17 years), with 12 females and three males. The mean time to surgery was 14.7 days post-injury (IQR: 12 days). The mean follow-up duration was 52 weeks (range: 8-234 weeks, IQR: 27 weeks) and variability was noted. The mean flexion-extension arc at the final follow-up was 93° (IQR: 32.5°). The mean OES was 46 (IQR: 22), and the mean MEPS was 75 (IQR: 37), indicating good to excellent functional outcomes. Scores for two patients were not available due to dementia. Reported complications included one case of ulnar sensory symptoms and one case requiring metalwork removal following olecranon osteotomy. Conclusion Primary elbow arthroplasty provides a viable treatment option for complex distal humerus fractures, demonstrating significant functional improvements and high patient satisfaction. However, the variability in follow-up and subjective decision-making underscores the need for standardized protocols. Future multicenter, prospective studies with larger cohorts and standardized follow-up protocols are recommended to confirm these findings and optimize patient care.

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BACKGROUND: While laparoscopic cholecystectomy has largely been performed in an outpatient setting in some countries for years, in Germany it is still generally performed on an inpatient basis; however, with the progressive ambitions for more outpatient treatment within the German healthcare system, laparoscopic cholecystectomy will (have to) increasingly be performed on an outpatient basis in the upcoming years. AIM OF THE WORK: Presentation of the current framework conditions and the potential for outpatient performance of laparoscopic cholecystectomy in Germany. Presentation and discussion on the current state of knowledge regarding patient selection, treatment pathways and safety of outpatient laparoscopic cholecystectomy. RESULTS: The potential for outpatient management of laparoscopic cholecystectomy in Germany is high. Based on the current literature, there are no safety concerns regarding outpatient performance of laparoscopic cholecystectomy in selected patients. CONCLUSION: Outpatient management of laparoscopic cholecystectomy is inevitably heading our way in the next years. The key to successful change will be comprehensive patient information, patient selection and structured outpatient treatment pathways.

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BACKGROUND: This study aimed to explore the clinical utility of targeted MECP2 testing in a large cohort of females with neurodevelopmental delays. Our aim was to identify suitable candidates for testing based on prevailing diagnostic criteria. METHODS: Eligible participants with global developmental delay/arrest or regression before age 36 months underwent MECP2 testing. MECP2-positive patients were further categorized based on Rett syndrome (RTT) diagnostic criteria, including typical, atypical, possible, and unclassified, to assess disease typicality and progression with respect to age. RESULTS: Of the 683 patients, 162 (23.7%) were diagnosed with MECP2-related RTT. Global developmental delay was the predominant initial symptom in approximately 75% of the cohort with developmental arrest/regression at testing. Symptoms emerged before age six months in 14 patients (8.6%). The average age at the time of MECP2 testing was 3.7 years, with 31.5% of the patients tested under two years. Of those under two years, 15 were initially categorized into the unclassified group; however, 12 were later reclassified into the typical/atypical RTT groups based on follow-up evaluation. Among the 119 patients monitored beyond age five years, 80% displayed typical RTT symptoms, 10 remained unclassified, and 9.8% had exonic deletions, posing challenges for detection using next-generation sequencing. CONCLUSIONS: Targeted MECP2 testing has emerged as a clinically valuable tool with a high diagnostic yield, including the identification of small deletions. Given that younger patients may not always meet the classic RTT criteria, this study recommends targeted MECP2 testing in younger patients without typical RTT features.

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The purpose of a first-in-human (FIH) clinical trial is to gather information about how the drug or device affects and interacts with the human body: its safety, side effects, and (potential) dosage. As such, the primary goal of a FIH trial is not participant benefit but to gain knowledge of drug or device efficacy, i.e., baseline human safety knowledge. Some FIH clinical trials carry significant foreseeable risk to participants with little to no foreseeable participant benefit. Participation in such trials would be a bad deal for participants, and the research is considered justifiable because of the promise of significant potential social benefit. I argue that there is an ethical tension inherent in risky FIH research and that researchers should fairly compensate risky FIH trial participants. This does not make the risk-benefit outcome more favorable for participants; rather, it amounts to a collective reckoning with the ethical tension inherent in the research.

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BACKGROUND: Deep venous outflow (VO) may be an important surrogate marker of collateral blood flow in acute ischemic stroke patients with a large vessel occlusion (AIS-LVO). Researchers have yet to determine the relationship between deep VO status in late-window patients and imaging measures of collaterals, which are key in preserving tissue. MATERIALS AND METHODS: We performed a multicenter retrospective cohort study on a subset of DEFUSE 3 patients recruited across 38 centers between May 2016 and May 2017 who underwent successful thrombectomy revascularization. Internal cerebral vein opacification was scored on a scale of 0-2. This metric was added to the cortical vein opacification score to derive the comprehensive VO (CVO) score from 0 to 8. Patients were stratified by favorable (ICV+) and unfavorable (ICV-) ICV scores, and similarly CVO+ and CVO-. Analyses comparing outcomes were primarily conducted by Mann-Whitney U and χ2 tests. RESULTS: Forty-five patients from DEFUSE 3 were scored and dichotomized into CVO+, CVO-, ICV+, and ICV- categories, with comparable demographics. Hypoperfusion intensity ratio, a marker of tissue level collaterals, was significantly worse in the ICV- and CVO- groups (p = 0.005). ICV- alone was also associated with a larger perfusion lesion (138 ml vs 87 ml; p = 0.023). No significant differences were noted in functional and safety outcomes. CONCLUSIONS: Impaired deep venous drainage alone may be a marker of poor tissue level collaterals and a greater degree of affected tissue in AIS-LVO patients presenting in the late-window who subsequently undergo successful revascularization.

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The use of video appointments (VAs) increased significantly during the COVID-19 pandemic. This study investigated the evolution of VA utilisation in Finland using data from two surveys conducted in 2021 (40 responses) and 2023 (30 responses). Our primary aim was to identify patient groups best suited for VAs. Respondents were either neurologists or neurologists-in-training. Our findings suggest that patients with epilepsy or headaches are most suitable for VAs. VAs were primarily used for follow-up visits during both survey periods, but their application for first visits decreased from 68.20% in 2021 to 27.80% in 2023. Healthcare professionals' concerns about data protection have diminished over time, but there is still need for enhanced training in the use of remote applications. Future research should focus on validating the cost-effectiveness, data security and timeliness of VAs.

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PURPOSE: To study the prioritization effects of the of COVID-19 pandemic on Swedish cataract surgery using a national healthcare registry with high coverage. SETTING: A study from the Swedish National Cataract Register (NCR), involving all patients undergoing cataract surgery in Sweden during 2019-2022 - before, during and after the COVID-19 pandemic. RESULTS: With the pandemic outbreak, the number of cataract surgeries fell by 22% in 2020 (15 369 procedures), albeit with large regional differences (-43% to +58%). The numbers recovered in 2021, and in 2022, a new top notation was seen (n = 149 952). On a national level, the patients were younger (-0.46 years, p < 0.001), with a larger proportion of less difficult cases (p < 0.001) and the proportion of males was higher (p < 0.001) during the pandemic, but all these variables also differed substantially between different regions and clinics. CONCLUSION: A national registry with high coverage can map the consequences of an event disrupting elective surgery in detail. During the COVID-19 pandemic, the impact on Swedish cataract surgery varied largely between different regions, clinics, and healthcare providers, leading to inequality in the availability of surgery. These differences likely owed to variations in healthcare policy approaches in different parts of the country. The present study shows that outcomes at one clinic or region cannot be extrapolated to larger regions under these circumstances. It actualizes the need to aim for a healthcare on equal terms, but it also shows a system that delivers care to many despite difficult times.

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A dramatic increase in the number of vascular procedures performed in the office-based laboratory setting has been observed since 2008, when the Centers for Medicare and Medicaid Services increased reimbursement for procedures performed in the ambulatory setting. We sought to evaluate the appropriateness of arterial intervention in the office-based laboratory and patient selection. This systematic review was conducted with a search of Google Scholar and PubMed using the following search terms: office-based lab, outpatient, angioplasty, patient selection, arterial, and appropriateness. More than 500 publications were screened and 14 publications related to the topic were selected. The existing literature that examined patient selection for intervention in the outpatient setting, rates of complications after outpatient procedures, and short-term data on the safety and efficacy of these procedures is discussed. Gaps were identified in current knowledge about the long-term outcomes of peripheral arterial interventions performed in the office-based laboratory setting, as well as existing guidelines for the management of patients with peripheral arterial disease.

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Study recruitment of persons with dementia is challenging. We aimed to assess facilitators, barriers, and strategies to identify and approach persons with dementia for recruitment to dementia care studies. We systematically searched MEDLINE/PubMed, CINAHL, Web of Science, and other sources (ORRCA [Online Resource for Research in Clinical triAls]; pertinent evidence syntheses; citation searching) and narratively summarised the results (PROSPERO CRD42022342600). Facilitators and barriers consisted of "characteristics of participants, researchers, clinical contact persons", "study characteristics", and "communication with participants". The highest number of participants were recruited by study information in electronic and print formats, as well as by networking and collaboration. Advertisements proved to be the most expensive way of recruitment. There is limited evidence on the impact of recruitment strategies to identify persons with dementia for recruitment to dementia care studies. Our analysis of facilitators and barriers may inform research teams in designing strategies to identify persons with dementia for recruitment purposes.

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Living donor liver transplantation (LDLT) is a curative treatment for various liver diseases, reducing waitlist times and associated mortality. We aimed to assess the overall survival (OS), identify predictors for mortality, and analyze differences in risk factors over time. Adult patients undergoing LDLT were selected from the United Network for Organ Sharing database from inception (1987) to 2023. The Kaplan-Meier method was used for analysis, and multivariable Cox proportional hazard models were conducted. In total, 7257 LDLT recipients with a median age of 54 years (interquartile range [IQR]: 45-61 years), 54% male, 80% non-Hispanic White, body mass index of 26.3 kg/m2 (IQR: 23.2-30.0 kg/m2), and model for end-stage liver disease score of 15 (IQR: 11-19) were included. The median cold ischemic time was 1.6 hours (IQR: 1.0-2.3 hours) with 88% right lobe grafts. The follow-up was 4.0 years (IQR: 1.0-9.2 years). The contemporary reached median OS was 17.0 years (95% CI: 16.1, 18.1 years), with the following OS estimates: 1 year 95%; 3 years 89%; 5 years 84%; 10 years 72%; 15 years 56%; and 20 years 43%. Nine independent factors associated with mortality were identified, with an independent improved OS in the recent time era (adjusted hazards ratio: 0.53; 95% CI: 0.39, 0.71). The median center-caseload per year was 5 (IQR: 2-10), with observed center-specific improvement of OS. LDLT is a safe procedure with excellent OS. Its efficacy has improved despite an increase of risk parameters, suggesting its limits are yet to be met.

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BACKGROUND: The COVID-19 pandemic had affected the health systems across the world since early 2020 with a concern about access to medical care during the first wave of COVID-19 pandemic. OBJECTIVES: The objective of this study was to examine how the COVID-19 pandemic influenced patient selection, approach type, and postoperative outcomes in elective bariatric surgery. SETTING: United States. METHODS: Data from the MBSAQIP database for the years 2016-2020 were queried. Wilcoxon rank-sum test and Fisher's exact test were employed for continuous and categorical variables, respectively. Postoperative outcomes within 30 days were assessed separately and based on the Clavien-Dindo (CD) classification of III-V. χ2 test and logistic regression were used to compare outcomes between procedure and approach types, as well as surgical operation periods. RESULTS: A total of 741,620 patients underwent robotic and laparoscopic sleeve gastrectomy and Roux-en-Y gastric-bypass. The cases performed in 2020 exhibited lower comorbidities and postoperative complications compared to prepandemic years, regardless of the approach type. Notably, the proportion of White patients decreased during the pandemic, while there was an increase in the number of African American and Hispanic patients who had bariatric surgery. CONCLUSIONS: Patients who underwent bariatric surgery during the COVID-19 pandemic appeared to be healthier with fewer comorbidities and experienced fewer adverse postoperative outcomes compared to those who had surgery prior to the pandemic. This study highlights the limited access to bariatric surgery for high-risk patients during the pandemic.

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Overly restrictive clinical trial eligibility criteria can reduce generalizability, slow enrollment, and disproportionately exclude historically underrepresented populations. The eligibility criteria for 196 Alzheimer's Disease and Related Dementias (AD/ADRD) trials funded by the National Institute on Aging were analyzed to identify common criteria and their potential to disproportionately exclude participants by race/ethnicity. The trials were categorized by type (48 Phase I/II pharmacological, 7 Phase III/IV pharmacological, 128 non-pharmacological, 7 diagnostic, and 6 neuropsychiatric) and target population (51 AD/ADRD, 58 Mild Cognitive Impairment, 25 at-risk, and 62 cognitively normal). Eligibility criteria were coded into the following categories: Medical, Neurologic, Psychiatric, and Procedural. A literature search was conducted to describe the prevalence of disparities for eligibility criteria for African Americans/Black (AA/B), Hispanic/Latino (H/L), American Indian/Alaska Native (AI/AN) and Native Hawaiian/Pacific Islander (NH/PI) populations. The trials had a median of 15 criteria. The most frequent criterion were age cutoffs (87% of trials), specified neurologic (65%), and psychiatric disorders (61%). Underrepresented groups could be disproportionately excluded by 16 eligibility categories; 42% of trials specified English-speakers only in their criteria. Most trials (82%) contain poorly operationalized criteria (i.e., criteria not well defined that can have multiple interpretations/means of implementation) and criteria that may reduce racial/ethnic enrollment diversity.

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OBJECTIVES: The development of the Popeye's deformity is a known complication of long head of the biceps tendon (LHBT) tenotomy. Incidence of developing Popeye's deformity after LHBT tenotomy ranges between 13% and 70%. While this complication is well tolerated, it can be avoided with proper patient selection. We aim to study patient and clinical factors resulting in the development of the Popeye's deformity after LHBT tenotomy so as to better identify suitable surgical candidates. METHODS: 91 patients underwent unilateral rotator cuff repairs and concomitant LHBT tenotomy between March 2013 and March 2017. Assessment of patient factors contributing to Popeye's deformity included patient demographics, and physical attributes were analyzed and correlated. Patients also completed a questionnaire regarding their overall postoperative satisfaction. Prospectively collated Visual Analog Pain Scale (VAS), Constant-Murley shoulder score (CSS), University of California, Los Angeles Shoulder Score (UCLA), and Oxford Shoulder Score (OSS) were compared at 6 and 24 months post operation between patients who developed Popeye's deformity and those who did not. RESULTS: The incidence of post-tenotomy Popeye's sign was 58.9%. Majority of patients were satisfied with their procedure, postoperative function, and cosmesis. Patients who developed Popeye's sign had a statistically significant lower body mass index (BMI) (24.9 â€‹± â€‹4.2 â€‹kg/m2 versus 27.3 â€‹± â€‹4.3 â€‹kg/m2, p â€‹= â€‹0.048) (rpb â€‹= â€‹- 0.210, p â€‹> â€‹0.05) and had a greater biceps-circumference-(in flexion)-to-wrist-circumference ratio (1.91 â€‹± â€‹0.16 versus 1.83 â€‹± â€‹0.13, p â€‹= â€‹0.012) (rpb â€‹= â€‹0.319, p â€‹< â€‹0.05) than those who did not. Nevertheless, the development of Popeye's sign did not affect clinical outcomes (VAS, CSS, UCLA, and OSS; p â€‹> â€‹0.05) at 24 months. CONCLUSIONS: The incidence of Popeye's deformity is high post LHBT tenotomy. There was a greater incidence in patients with lower BMI and greater biceps brachii muscle bulk. However, this complication is well tolerated. By better selecting our patients, we can achieve better outcomes and minimize potential complications. LEVEL OF EVIDENCE: Level-III evidence. TYPE OF STUDY: Retrospective comparative study.

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BACKGROUND: Oral treprostinil is a prostacyclin analogue approved to treat pulmonary arterial hypertension (PAH) by delaying disease progression and improving exercise capacity. Higher doses of oral treprostinil correlate with increased treatment benefit. Titrations may be challenging due to common side effects of prostacyclin-class therapies. STUDY DESIGN AND METHODS: The multicenter, prospective, real-world, observational ADAPT Registry study followed adult patients with PAH for up to 78 weeks after initiating oral treprostinil (NCT03045029). Dosing, titration, and transitions of oral treprostinil were at the discretion of the prescriber. Patient-reported incidence and treatment of common side effects were collected to understand side effect management and tolerability. Insights from literature and expert recommendations were added to provide a consolidated resource for oral treprostinil use. RESULTS: In total, 139 participants in ADAPT completed ≥1 weekly survey; (median age 60.0 years, 76 % female). Median treatment duration of oral treprostinil was 13.1 months. During early therapy (Months 1-5), 62 % (78/126) of patients reported headache and diarrhea, and 40 % (50/126) reported nausea. At Month 6, many patients who reported side effects during early therapy reported an improvement (61 % headache, 44 % diarrhea, 70 % nausea). Common side effect treatments, including acetaminophen, loperamide, and ondansetron, were effective. Approximately one-quarter of patients reporting the most common side effects were untreated at Month 6. CONCLUSION: Patient selection for, and initiation and titration of, oral treprostinil should be individualized and may include parenteral treprostinil induction-transition for faster titration. Assertive side effect management may help patients reach higher and more efficacious doses of oral treprostinil.

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Purpose: This study explored whether a free-breathing mean heart dose (FB-MHD) of 4 Gy is a reliable dose threshold for selecting left breast cancer patients after modified radical mastectomy suitable for deep inspiration breath-hold (DIBH) and developed anatomical indicators to predict FB-MHD for rapid selection. Materials and methods: Twenty-three patients with left breast cancer treated with DIBH were included to compare FB and DIBH plans. The patients were divided into the high-risk (FB-MHD ≥ 4 Gy) and low-risk (FB-MHD < 4 Gy) groups to compare dose difference, normal tissue complication probability (NTCP) and the DIBH benefits. Another 30 patients with FB only were included to analyze the capacity of distinguishing high-risk heart doses patients according to anatomical metrics, such as cardiac-to-chest Euclidean distance (CCED), cardiac-to-chest gap (CCG), and cardiac-to-chest combination (CCC). Results: All heart doses were significantly lower in patients with DIBH plans than in those with FB plans. Based on FB-MHD of 4 Gy cutoff, the heart dose, NTCP for cardiac death, and benefits from DIBH were significantly higher in the high-risk group than in the low-risk group. The CCED was a valid anatomical indicator with the largest area under the curve (AUC) of 0.83 and maintained 95 % sensitivity and 70 % specificity at the optimal cutoff value of 2.5 mm. Conclusions: An FB-MHD of 4 Gy could be used as an efficient dose threshold for selecting patients suitable for DIBH. The CCED may allow a reliable prediction of FB-MHD in left breast cancer patients at CT simulation.

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Clinical Vignette: A 63-year-old man with severe essential tremor underwent staged bilateral ventralis intermedius (Vim) deep brain stimulation (DBS). Left Vim DBS resulted in improved right upper extremity tremor control. Months later, the addition of right Vim DBS to the other brain hemisphere was associated with acute worsening of the right upper extremity tremor. Clinical Dilemma: In staged bilateral Vim DBS, second lead implantation may possibly alter ipsilateral tremor control. While ipsilateral improvement is common, rarely, it can disrupt previously achieved benefit. Clinical Solution: DBS programming, including an increase in left Vim DBS amplitude, re-established and enhanced bilateral tremor control. Gap in Knowledge: The mechanisms underlying changes in ipsilateral tremor control following a second lead implantation are unknown. In this case, worsening and subsequent improvement after optimization highlight the potential impact of DBS implantation on the ipsilateral side. Expert Commentary: After staged bilateral Vim DBS, clinicians should keep an eye on the first or original DBS side and carefully monitor for emergent side effects or worsening in tremor. Ipsilateral effects resulting from DBS implantation present a reprogramming opportunity with a potential to further optimize clinical outcomes. Highlights: This case report highlights the potential for ipsilateral tremor worsening following staged bilateral DBS and provides valuable insights into troubleshooting and reprogramming strategies. The report emphasizes the importance of vigilant monitoring and individualized management in optimizing clinical outcomes for patients undergoing staged bilateral DBS for essential tremor.

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Background: The adoption of robotic bariatric surgery has increased dramatically over the last decade. While outcomes comparing bariatric and laparoscopic approaches are debated, little is known about patient factors responsible for the growing delivery of robotic surgery. A better understanding of these factors will help guide the planning of bariatric delivery and resource allocation. Methods: Data were extracted from the MBSAQIP registry from 2020 to 2021. The patient population was organized into primary robot-assisted sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) versus those who underwent laparoscopic procedures. Bivariate analysis and multivariable logistic regression modeling were conducted to characterize cohort differences and identify independent patient predictors of robotic selection. Results: Of 318,151, 65,951 (20.7%) underwent robot-assisted surgery. Patients undergoing robotic procedures were older (43.4 ± 11.8 vs. 43.1 ± 11.8; p < 0.001) and had higher body mass index (BMI; 45.4 ± 7.9 vs. 45.0 ± 7.6; p < 0.001). Robotic cases had higher rates of medical comorbidities, including sleep apnea, hyperlipidemia, gastroesophageal reflux disease (GERD), and diabetes mellitus. Robotic cases were more likely to undergo RYGB (27.4% vs. 26.4%; p < 0.001). Robotic patients had higher rates of numerous complications, including bleed, reoperation, and reintervention, resulting in higher serious complication rates on multivariate analysis. Independent predictors of robotic selection included increased BMI (aOR 1.02), female sex (aOR 1.04), GERD (aOR 1.12), metabolic dysfunction, RYGB (aOR 1.08), black racial status (aOR 1.11), and lower albumin (aOR 0.84). Conclusions: After adjusting for comorbidities, patients with greater metabolic comorbidities, black racial status, and those undergoing RYGB were more likely to receive robotic surgery. A more comprehensive understanding of patient factors fueling the adoption of robotic delivery, as well as those expected to benefit most, is needed to better guide healthcare resources as the landscape of bariatric surgery continues to evolve.

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Vascularized Composite Allotransplantation (VCA) offers a unique option to restore form and function after limb loss or facial trauma that cannot be satisfactorily accomplished through traditional prosthetics or reconstructions. Establishing a successful Upper Extremity Transplantation (UET) program requires strong leadership and a structured surgical team, and extensive interdisciplinary collaboration. We conducted a qualitative study among 12 health care professionals and patients. Informed consent was obtained per protocol, and semi-structured interviews were conducted online and recorded. Participants reported their perceptions of factors that either favored or hindered a successful outcome, including functional status before and after surgery, preparation for transplant, shared decision-making, rehabilitation, and psychosocial support. Thematic analysis revealed that it is essential to establish a team comprising various disciplines well before performing VCA procedures. Defining a common goal and choosing a defined leader is a key factor in procedural success and requires open collaboration beyond what is typical. Primary described categories are interdisciplinary collaboration and skills of the VCA team, building and leading a VCA team, pre-transplant procedures, post-transplant course, and factors to consider when establishing a program. The basic roles of team science play an outsized role in establishing a VCA program. Transplantation medicine involves various overlapping scientific and medical categories requiring health professionals to consciously work together to establish complex vertical and horizontal communication webs between teams to obtain positive outcomes. In addition to medical considerations, patient-specific factors such as transparent communication, therapy plan establishment, plan adherence, and continual follow-up are significant factors to overall success.

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Chronic low back pain (CLBP) is a debilitating, painful, and costly condition. Implantable neuromuscular electrical stimulation targeting the multifidus musculature is growing as a non-pharmacologic option for patients with recalcitrant nociceptive mechanical CLBP who have failed conservative treatments (including medications and physical therapy) and for whom surgery is not indicated. Properly selecting patients who meet specific criteria (based on historical results from randomized controlled trials), who diligently adhere to implant usage and precisely implement neuromuscular rehabilitation, improve success of significant functional recovery, as well as pain medication reductions. Patients with nociceptive mechanical CLBP who underwent implanted multifidus neurostimulation have been treated by physicians and rehabilitation specialists who have honed their experience working with multifidus neurostimulation. They have collaborated on consensus and evidence-driven guidelines to improve quality outcomes and to assist providers when encountering patients with this device. Physicians and physical therapists together provide precision patient-centric medical management with quality neuromuscular rehabilitation to encourage patients to be experts of both their implants and quality spine motion to help override long-standing multifidus dysfunction related to their CLBP.