A literature review is provided concerning the scientific studies that have been published involving high-intensity focused ultrasound (HIFU) as a therapeutic treatment for tumors of the prostate, uterus, and brain. This is a revival of earlier work that now focuses on targeted therapy with sonography, but the studies that have been conducted vary in their level of evidence and translation to clinical practice. The review arranges the published studies by levels of evidence and provides a meta-analysis of the potential for using HIFU to treat prostate cancer, fibroids, and glioblastomas. Human studies are needed that provide clear levels of frequency, intensity, temperature, and treatment patterns. The bioeffects of sonography play a huge role in the destruction of these tumors as well as the potential to cause collateral damage in the surrounding healthy tissue. The hope is that with continued research, a fusion of technology with HIFU can provide patients with a noninvasive, nonionizing therapy for these lesions.

These data suggest that fiducial markers used in conjunction with MV-CBCT improve the accuracy of daily target delineation compared with localisation using adjacent bony anatomy and that gold fiducial markers using MV-CBCT alignment are a viable option for target localisation during IG-IMRT.

Spinal metastasis is usually associated with debilitating pain and results in deteriorating life quality. The role of percutaneous management of spinal metastasis has evolved from a diagnostic role to a significant part of therapeutic options in conjunction with conventional management techniques, including radiotherapy and open surgical options. Percutaneous vertebral augmentation (PVA) showed substantial pain reduction, vertebral stabilization, and improvement of quality of life. Minimally invasive local ablative procedures (MILAPs) demonstrated significant pain reduction, local tumor burden control, and improvement of quality of life. Though combined PVA and MILAP's synergistic role in pain reduction may need additional investigation, considering different actions on spine metastasis patients, combining both techniques might beneficial to selected patients. The role of percutaneous management will likely expand since its role in improving patient's quality of life with very minimal procedure-related risk and in conjunction with future technological advancement.

Study Design. Retrospective single-institution study.Objective. The aim of this study was to determine the relationship between patients' insurance status and the likelihood for them to be recommended various spine interventions upon evaluation in our neurosurgical clinics. Summary of Background Data. Socioeconomically disadvantaged populations have worse outcomes after spine surgery. No studies have looked at the differential rates of recommendation for surgery for patients presenting to spine surgeons based on socioeconomic status. Methods. We studied patients initially seeking spine care from spine-fellowship trained neurosurgeons at our institution from July 1, 2018 to June 30, 2019. Multivariable logistic regression was used to assess the association between insurance status and the recommended patient treatment. Results. Overall, 663 consecutive outpatients met inclusion criteria. Univariate analysis revealed a statistically significant association between insurance status and treatment recommendations for surgery (P < 0.001). Multivariate logistic regression demonstrated that compared with private insurance, Medicare (odds ratio [OR] 3.54, 95% confidence interval [CI] 1.21-7.53, P ¼ 0.001) and Medicaid patients (OR 2.46, 95% CI 1.21-5.17, P ¼ 0.014) were more likely to be recommended for surgery. Uninsured patients did not receive recommendations for surgery at significantly different rates than patients with private insurance. Conclusion. Medicare and Medicaid patients are more likely to be recommended for spine surgery when initially seeking spine care from a neurosurgeon. These findings may stem from a number of factors, including differential severity of the patient's condition at presentation, disparities in access to care, and differences in shared decision making between surgeons and patients.

Requirements for most minerals are expressed on an absorbed basis. The true absorption of minerals can vary widely because of source, presence of antagonists, dietary concentrations, and animal mineral status; therefore, expressing mineral requirements on an absorbed basis is theoretically sound. Unfortunately measuring true absorption of minerals is exceedingly difficult; available data is limited which means that often we are using constants. Requirements for lactation, growth, and conceptus growth are known with reasonable certainty; however establishing maintenance requirements is plagued with methodological difficulties, and the classical definition of maintenance (i.e., replenishment of inevitable fecal and urinary losses) ignores effects on water balance, acid-base balance in the rumen, and the ruminal and intestinal microbiome. For Na, Cl- and K, absorption is essentially 100% regardless of source. Lab methods are available to estimate absorption of P. Source of Ca accounts for the majority of the variation in Ca absorption and constants are available for feedstuffs and supplements. We have good data on absorption of Mg from basal diets and are able to estimate antagonism of Mg absorption caused by K. We are less able to estimate absorption of the various Mg supplements, some of which are highly variable. Except for the electrolytes (which affect water balance), requirements are known with reasonable certainty for macrominerals. Absorption coefficients for trace minerals (TM) are known with much less certainty. Source of supplemental TM (e.g., organic vs sulfates) can affect absorption but the effect depends on the mineral TM (e.g., source affects absorption of Cu more than that of Mn) and on interactions with basal diet. Maintenance requirements are generally poorly defined for TM and because of ‘non-factorial’ requirements such as effects on microbiome, source of TM likely affects requirements. This means that for some TM, the factorial approach to requirements may not be adequate.

Study Design. Case series. Objective. To evaluate the impact of a multidisciplinary spine surgery indications conference (MSSIC) on surgical planning for elective spine surgeries. Summary of Background Data. Identifying methods for pairing the proper patient with the optimal intervention is of the utmost importance for improving spine care and patient outcomes. Prior studies have evaluated the utility of multidisciplinary spine conferences for patient management, but none have evaluated the impact of a MSSIC on surgical planning and decision making. Methods. We implemented a mandatory weekly MSSIC with all spine surgeons at our institution. Each elective spine surgery in the upcoming week is presented. Subsequently, a group consensus decision is achieved regarding the best treatment option based on the expertise and opinions of the participating surgeons. We reviewed cases presented at the MSSIC from September 2019 to December 2019. We compared the surgeon's initial proposed surgery for a patient with the conference attendees’ consensus decision on the best treatment and measured compliance rates with the group's recommended treatment. Results. The conference reviewed 100 patients scheduled for elective spine surgery at our indications conference during the study period. Surgical plans were recommended for alteration in 19 cases (19%) with the proportion statistically significant from zero indicated by a binomial test (P < 0.001). The median absolute change in the invasiveness index of the altered procedures was 3 (interquartile range [IQR] 1–4). Participating surgeons complied with the group's recommendation in 96.5% of cases. Conclusion. In conjunction with other multidisciplinary methods, MSSICs can lead to surgical planning alterations in a significant number of cases. This could potentially result in better selection of surgical candidates and procedures for particular patients. Although long-term patient outcomes remain to be evaluated, this care model will likely play an integral role in optimizing the care spine surgeons provide patients. Level of Evidence: 4

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Chronic back and leg pain are leading causes of disability worldwide. The purpose of this study was to compare the care in a unidisciplinary (USC) versus multidisciplinary (MSC) spine clinic, where patients are evaluated by different specialists during the same office visit. Adult patients presenting with a chief complaint of back and/or leg pain between June 2018 and July 2019 were assessed for eligibility. The main outcome measures included the first treatment recommendations, the time to treatment order, and the time to treatment occurrence. A 1:1 propensity score-matched analysis was performed on 874 patients (437 in each group). For all patients, the most common recommendation was physical therapy (41.4%), followed by injection (14.6%), and surgery (9.7%). Patients seen in the MSC were more likely to be recommended injection (p < 0.001) and less likely to be recommended surgery as first treatment (p = 0.001). They also had significantly shorter times to the injection order (log-rank test, p = 0.004) and the injection occurrence (log-rank test, p < 0.001). In this study, more efficient care for patients with back and/or leg pain was delivered in the MSC setting, which was evidenced by the shorter times to the injection order and occurrence. The impact of the MSC approach on patient satisfaction and health-related quality-of-life outcome measures warrants further investigation.