BACKGROUND: Despite their precarious behavioral classification (benign and low grade on histopathology yet behaviorally malignant), great strides have been taken to improve prognostication and treatment paradigms for patients with skull base chordoma. With respect to surgical techniques, lateral transcranial (TC) approaches have traditionally been used, however endoscopic endonasal approaches (EEA) have been advocated for midline lesions. Nonetheless, due to the rarity of this pathology (0.2% of all intracranial neoplasms), investigations within the literature remain limited to small retrospective series. Furthermore, radiotherapeutic treatments investigated to date have proven largely ineffective.
METHODS: Accordingly, we performed a systematic review in order to profile surgical and survival outcomes for skull base chordoma. Fixed and random-effect meta-analyses were performed for categorical variables including GTR, STR, 5-year OS, 10-year OS, 5-year PFS, and 10-year PFS. Additionally, we pooled eligible studies for formal meta-analysis to compare outcomes by surgical approach (lateral versus midline). Statistical analyses were performed using R Studio \'metafor\' package or Cochrane Review Manager. Furthermore, meta-analysis of pooled mortality rates and sub-analyses of operative margin and surgical complications were used to compare midline versus lateral approaches via the Mantel-Haenszel method. We considered all p-values < 0.05 to be statistically significant.
RESULTS: Following the systematic search and screen, 55 studies published between 1993 and 2022 reporting data for 2453 patients remained eligible for analysis. Sex distribution was comparable between males and females, with a slight predominance of male-identifying patients (0.5625 [95% CI: 0.5418; 0.3909]). Average age at diagnosis was 42.4 ± 12.5 years, while average age of treatment initiation was 43.0 ± 10.6 years. Overall, I2 value indicated notable heterogeneity across the 55 studies [I2 = 56.3% (95%CI: 44.0%; 65.9%)]. With respect to operative margins, the rate of GTR was 0.3323 [95% CI: 0.2824; 0.3909], I2 = 91.9% [95% CI: 90.2%; 93.4%], while the rate of STR was significantly higher at 0.5167 [95% CI: 0.4596; 0.5808], I2 = 93.1% [95% CI: 91.6%; 94.4%]. The most common complication was CSF leak (5.4%). In terms of survival outcomes, 5-year OS rate was 0.7113 [95% CI: 0.6685; 0.7568], I2 = 91.9% [95% CI: 90.0%; 93.5%]. 10-year OS rate was 0.4957 [95% CI: 0.4230; 0.5809], I2 = 92.3% [95% CI: 89.2%; 94.4%], which was comparable to the 5-year PFS rate of 0.5054 [95% CI: 0.4394; 0.5813], I2 = 84.2% [95% CI: 77.6%; 88.8%] and 10-yr PFS rate of 0.4949 [95% CI: 0.4075; 0.6010], I2 = 14.9% [95% CI: 0.0%; 87.0%]. There were 55 reported deaths for a perioperative mortality rate of 2.5%. The relative risk for mortality in the midline group versus the lateral approach group did not indicate any substantial difference in survival according to laterality of approach (-0.93 [95% CI: -1.03, -0.97], I2 = 95%, (p < 0.001).
CONCLUSIONS: Overall, these results indicate good 5-year survival outcomes for patients with skull base chordoma; however, 10-year prognosis for skull base chordoma remains poor due to its radiotherapeutic resistance and high recurrence rate. Furthermore, mortality rates among patients undergoing midline versus lateral skull base approaches appear to be equivocal.

UNASSIGNED: Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse effects of these catheters. We aimed to evaluate the relative risk of complications from midlines and PICCs.
UNASSIGNED: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. The primary outcomes were catheter-related bloodstream infection (CRBSI) and thrombosis. Secondary outcomes evaluated included mortality, failure to complete therapy, catheter occlusion, phlebitis, and catheter fracture. The certainty of evidence was assessed using the GRADE approach.
UNASSIGNED: Of 8368 citations identified, 20 studies met the eligibility criteria, including 1 RCT and 19 observational studies. Midline use was associated with fewer patients with CRBSI compared with PICCs (odds ratio [OR], 0.24; 95% CI, 0.15-0.38). This association was not observed when we evaluated risk per catheter. No significant association was found between catheters when evaluating risk of localized thrombosis and pulmonary embolism. A subgroup analysis based on location of thrombosis showed higher rates of superficial venous thrombosis in patients using midlines (OR, 2.30; 95% CI, 1.48-3.57). We did not identify any significant difference between midlines and PICCs for the secondary outcomes.
UNASSIGNED: Our findings suggest that patients who use midlines might experience fewer CRBSIs than those who use PICCs. However, the use of midline catheters was associated with greater risk of superficial vein thrombosis. These findings can help guide future cost-benefit analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs vs midline catheters.

Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). The aim of this study was to determine pooled incidence of IH for each type of extraction site and to compare rates of IH after midline, nonmidline and Pfannenstiel extraction.
A systematic review and meta-analysis was conducted using the PRISMA guidelines. Single-armed and multiple-armed cohort studies and randomized controlled trials regarding minimally invasive colorectal surgery were searched from five databases. Outcomes were pooled and compared with random-effects, inverse-variance models. Risk of bias within the studies was assessed using the Cochrane ROBINS-I and RoB 2 tool.
Thirty six studies were included, with a total 11,788 patients. The pooled extraction site IH rate was 16.0% for midline (n = 4081), 9.3% for umbilical (n = 2425), 5.2% for transverse (n = 3213), 9.4% for paramedian (n = 134) and 2.1% for Pfannenstiel (n = 1449). Nonmidline extraction (transverse and paramedian) showed significantly lower odds ratios (ORs) for IH when compared with midline extraction (including umbilical). Pfannenstiel extraction resulted in a significantly lower OR for IH compared with midline [OR 0.12 (0.50-0.30)], transverse [OR 0.25 (0.13-0.50)] and umbilical (OR 0.072 [0.033-0.16]) extraction sites. The risks of surgical site infection, seroma/haematoma or wound dehiscence were not significantly different in any of the analyses.
Pfannenstiel extraction is the preferred method in minimally invasive colorectal surgery. In cases where Pfannenstiel extraction is not possible, surgeons should avoid specimen extraction in the midline.

OBJECTIVE: Dermoid cysts/sinuses (DCS) are congenital masses occurring along lines of embryonic fusion. Midline DCS carry a risk of intracranial extension. Pre-operative computed tomography (CT) or magnetic resonance imaging (MRI) are the primary imaging modalities used and based on the results, the need to involve a neurosurgical team in the resection is determined. Although less so, non-midline locations are also at risk for intracranial communication. This study aims to quantify our institutional experience with both midline and lateral DCS for intracranial extension and discuss potential need for preoperative imaging in all DCS cases.
METHODS: Institutional Review Board approval was obtained. Pediatric patients ages 0-18 years with DCS presenting to the pediatric otolaryngology, plastic surgery, and neurosurgery clinics from 2005 to 2020 were retrospectively reviewed. Data collected included patient demographics, imaging modality, location, size, complications, and presence/absence of intracranial extension. DCS location included nasoethmoidal (NE), periorbital, frontotemporal (FT), and scalp. Lesions were further classified as midline and non-midline.
RESULTS: 205 patients with surgically removed DCS were included for analysis. Mean age at surgery was 3 years. MRI was the most common imaging modality used (60.5%), followed by US (18%), CT (18%) and plain films (1%). Locations were: NE (69, 34%), periorbital (67, 33%), FT (28, 14%), and scalp (41, 20%). 105 DCS were midline: NE (69), periorbital (7), and scalp (29). Of these, 29 (28%) had intracranial extension: NE (8), scalp (21). 100 DCS were non-midline: periorbital (60), FT (28) and scalp (12). Of these, 7 (7%) had intracranial extension: periorbital (3), FT (3) and scalp (1).
CONCLUSIONS: The risk of intracranial extension of midline craniofacial DCS is well established. We have shown that there is a percentage of lateral DCS which carry a risk for intracranial extension, and for which the involvement of a neurosurgical team may be required. Given the potential benefit, pre-operative imaging of all lateral head and neck DCS may be prudent to screen for intracranial extension.

OBJECTIVE: Our understanding of diffuse midline glioma (DMG) biology inclusive of diffuse intrinsic pontine glioma has been revolutionized by the discovery of novel mutations on the tails of histone 3, leading to the reclassification in 2016 of \'diffuse midline glioma, H3 K27M-mutant.\' Given the abundance of basic, translational, and clinical information put forth in recent years, a review of the epigenetics of diffuse midline glioma is warranted.
METHODS: Literature for the epigenetics of diffuse midline glioma published from 1989 to 2019 was reviewed by searching PubMed using the terms \"diffuse intrinsic pontine glioma\", \"pontine glioma\", or \"midline glioma\". The final references list was generated on the basis of originality and relevance to the broad scope of our review.
RESULTS: The effects of H3K27M-mutation, while better understood, suggest multiple consequences on the chromatin landscape and DNA modification states, contributed to the progression of DMG. A rapid pace of translational development is occurring for epigenetic modifiers, and several classes of inhibitors have already made their way into clinical trial testing. As more agents become clinically accessible, immense effort is underway to understand the target effects, tumor penetration, and immune microenvironmental changes of epigenetic modification.
CONCLUSIONS: We continue to seek a comprehensive understanding of the mechanisms that govern chromatin dysregulation and DNA modification in DMG, and in parallel we forge ahead with clinical testing of epigenetic modifiers. The determined efforts from bench to bedside, along with collaborative mindset and unified mission, will ultimately result in improved outcomes for DMG.

Long peripheral catheters (LPCs) offer a quick, simple and cost-effective alternative for venous access in intensive care patients with difficult venous access, but the decision to use them must be balanced against an assessment of harm. The aim of this systematic review was to synthesise reports of complications associated with LPCs.
The electronic databases MEDLINE, EMBASE and CINAHL were searched systematically for randomised controlled trials, cohort studies and case control studies published in the period 1966 to 24th July 2018 reporting LPC associated occlusion, catheter related blood stream infections, phlebitis and infiltration. Study quality was assessed using the Methodological Index for Non-Randomised Studies. The studies were described and participant characteristics; type of catheter; setting; average dwell time; and rates of occlusion, catheter related blood stream infection, phlebitis and infiltration were extracted as summary measures.
Five cohort studies and one randomised controlled study, comprising a total of 350 participants, fulfilled the inclusion criteria. Dwell time ranged from 1 to 15days and the reported complication rate was 3-14%. The most common complication was catheter occlusion (4%), followed by phlebitis (1%), infiltration (0.9%), and catheter related blood stream infection (0.3%). Significant heterogeneity, particularly in identification and reporting of complications, means results should be interpreted with caution.
There is a lack of intervention specific and adequately powered randomised controlled trials investigating LPCs in an intensive care setting. Until the results of such studies are available, LPCs should be used as an alternative to ultrasound-guided PVCs in well monitored acute care environments.

UNASSIGNED: The aim is to evaluate the association between midline discrepancies and tempromandibular disorders (TMDs).
UNASSIGNED: Literature search was performed by using various search engines to include human studies in English. TMDs include a wide variety of signs and symptoms such as pain in and around TMJ, jaw muscles, clicking and locking of jaws, pain during mandibular movement and restricted mandibular movements. The etiology is multifactorial, including one or several of the following factors like severe malocclusions (increased overjet, retroclination of incisors, cross bite, CR CO discrepancies etc), stress and psychological factors, structural abnormalities as possible etiology. There are controversies concerning the association between different traits of malocclusion and TMDs. The aim of the present study was to find out any association between signs and symptoms of TMDs with midline discrepancies, which represent an important trait of malocclusion.
UNASSIGNED: Of the seven studies evaluated in this systematic review for investigating the association between midline discrepancy and TMD, six had moderate grade (B) of evidence. Four studies of moderate grade evidence (B) showed a significant association between the presence of midline shift and TMDs, and the remaining studies (two) had non-significant association. Only one study had a strong grade of evidence (A) and interestingly it denies the presence of midline shift to be a causative factor for TMDs. So, it can be concluded that the results are inconclusive regarding the association of midline discrepancies with TMDs. Nonetheless, this requires concrete evidence which necessitates further long term research into this aspect.

Childbirth can be a traumatic experience on the female body. Some techniques may be implemented to make the process smoother and decrease the potential lacerations that can occur. Episiotomies have been used by obstetricians and midwives to help make the fetal decent down the vaginal canal less turbulent. A physician must use his best judgment on when it is necessary to make this incision and what form of incision to make. Before making an incision one must understand the female external and internal anatomy and thoroughly comprehend the stages of birth to understand how and what complications can occur. Even though an episiotomy is a minor incision, it is still a surgical incision nonetheless and as with any form of surgery there are both risks and benefits that are to be considered. Nevertheless, episiotomies have proven to help ease births that are complicated by shoulder dystocia, prevent severe lacerations, and decrease the second stage of labor. The following comprehensive review provides a description of the female anatomy, as well as an extensive description of why, when, and how an episiotomy is done. Clin. Anat. 30:362-372, 2017. © 2017 Wiley Periodicals, Inc.

BACKGROUND: Venous access in the emergency department (ED) is an often under-appreciated procedural skill given the frequency of its use. The patient\'s clinical status, ongoing need for laboratory investigation, and intravenous therapeutics guide the size, type, and placement of the catheter. The availability of trained personnel and dedicated teams using ultrasound-guided insertion techniques in technically difficult situations may also impact the selection. Appropriate device selection is warranted on initial patient contact to minimize risk and cost.
OBJECTIVE: To compare venous access device indications and complications, highlighting the use of midline catheters as a potentially cost-effective and safe approach for venous access in the ED.
CONCLUSIONS: Midline catheters (MC) offer a comparable rate of device-related bloodstream infection to standard peripheral intravenous catheters (PIV), but with a significantly lower rate than peripherally inserted central catheters (PICC) and central venous catheters (CVC) (PIV 0.2/1000, MC 0.5/1000, PICC 2.1-2.3/1000, CVC 2.4-2.7/1000 catheter days). The average dwell time of a MC is reported as 7.69-16.4 days, which far exceeds PIVs (2.9-4.1 days) and is comparable to PICCs (7.3-16.6 days). Cost of insertion of a MC has been cited as comparable to three PIVs, and their use has been associated with significant cost savings when placed to avoid prolonged central venous access with CVCs or in patients with difficult-to-access peripheral veins. Placement of a MC includes modified Seldinger and accelerated, or all-in-one, Seldinger techniques with or without ultrasound guidance, with a high rate of first-attempt success.
CONCLUSIONS: The MC is a versatile venous access device with a low complication rate, long dwell time, and high rate of first-attempt placement. Its utilization in the ED in patients deemed to require prolonged hospitalization or to have difficult-to-access peripheral vasculature could reduce cost and risk to patients.

OBJECTIVE: Dural sinus malformations (DSMs) are rare pediatric vascular lesions that have variable presentations and outcomes. We present three cases of midline DSMs and discuss the treatment strategy employed for each lesion. A review of the literature was completed to summarize current literature and treatment practices.
METHODS: A retrospective review of the electronic medical record and all available imaging studies was performed for each of our patients.
RESULTS: Patient 1 had a prenatally diagnosed DSM which decreased in size despite no intervention. She was born without complication and continues to do well at 15 months of age. Patient 2 presented 2 weeks after birth with cardiac failure, intracranial hemorrhage, and seizures and imaging showed a large midline DSM with multiple high-flow shunts. She required multiple endovascular embolizations with complete occlusion of the lesion. At her 3-year follow-up, she was neurologically normal. The third patient was diagnosed prenatally with an enlarging DSM. Multiple endovascular embolizations, surgical decompression, cranial expansion, and CSF diversion were required for treatment. At her 2.5-year follow-up, she was meeting developmental milestones, with some motor delay.
CONCLUSIONS: Early diagnosis and treatment, if necessary, of DSMs are critical to prevent cardiac failure or parenchymal injury from chronic venous hypertension. Management should be decided on individual case basis depending on the angioarchitecture and progression of the lesion and can involve observation, endovascular embolization, surgical interventions, or a combination of treatments. A personalized approach to treating these variable lesions can be associated with good outcomes.