Ria Pal

Deep medullary vein thrombosis (DMVT) is an increasingly recognized etiology of neonatal brain injury, but remains poorly understood. Our study aimed to assess the association between MRI severity and neurodevelopmental impairment (NDI) in neonates with DMVT, and develop a novel MRI grading system that might inform clinical outcomes. We retrospectively reviewed relevant charts from infants admitted to our tertiary care hospital between January 1990 to March 2023, and evaluated clinical characteristics, MRI features, and neurodevelopmental assessments of this cohort. We developed and validated a simple MRI grading system based on injury severity, categorizing lesions into mild, moderate, or severe groups. Of the 63 neonates with a diagnosis of DMVT, 41 had moderate or severe MRI lesions; those patients were 24-fold more likely to experience NDI compared to those with mild injury (adjusted OR 24.3, 95% CI 4.7-180.2, p<0.001). Of the 52 infants with follow-up data, 40.4% developed NDI; MRI severity was the strongest predictor of impaired outcomes, independent of clinical factors including gestational age, Apgar score and seizures at presentation. Our findings suggest that this pragmatic MRI grading scheme may offer clinicians and researchers a valuable classification and prognostication tool.

There is a growing trend of resident and fellow physician unionization in the United States, with 14 new housestaff unions formed at private employers since 2022. This resurgence of housestaff union organizing parallels the last era of housestaff activism in the 1960s. Today’s housestaff organizing takes place within the context of long-standing challenges in medicine, including the burnout and systemic inequities highlighted by the COVID-19 pandemic, and an increase in national activism and labor organizing. Housestaff unions offer opportunities for residents and fellows to negotiate for improvements across multiple issues. In this Commentary, the authors focus on common bargaining topics: poor working conditions, undercompensation, and inadequate representation in an increasingly corporatized health care landscape. The authors also discuss the role of collective bargaining for improving the housestaff experience and address common concerns about unionization. Finally, the authors explore the limited evidence of the impact of unions in health care settings and outline key considerations for future scholarship. The current generation of housestaff started their medical careers with an awareness of systemic challenges to the profession and has responded through collective organizing. While the short- and long-term ramifications of housestaff organizing need further study, the authors express optimism that unionization will lead to improved working conditions and thus improved health care delivery.

This is a multicenter retrospective EMR-based chart review of 88 patients aged 3–21 years admitted for evaluation of functional neurologic disorder (FND). We sought to establish characteristics associated with FND, calculate incidence of abnormal neurodiagnostic findings, and determine features associated with variability in workup and treatment. FND patients were 65% female, 40% White, 33% Hispanic, and 88% primarily English speaking with median 13.9 years. We detected variability in management by age, ethnicity, psychiatric comorbidity, and hospital site. Our findings suggest limited utility to CTs in this setting (100% normal) and that workup can be safely informed by physical exam, which predicted abnormal MRI and LP results. We favor screening for adverse childhood experiences in FND patients. Hospitalization may be a rare opportunity for psychiatry contact.

The central extended amygdala (CEA) has been conceptualized as a ‘macrosystem’ that regulates various stress-induced behaviors. Consistent with this, the CEA highly expresses corticotropin-releasing factor (CRF), an important modulator of stress responses. Stress alters goal-directed responses associated with striatal paths, including maladaptive responses such as drug seeking, social withdrawal, and compulsive behavior. CEA inputs to the midbrain dopamine (DA) system are positioned to influence striatal functions through mesolimbic DA-striatal pathways. However, the structure of this amygdala-CEA-DA neuron path to the striatum has been poorly characterized in primates. In primates, we combined neuronal tracer injections into various arms of the circuit through specific DA subpopulations to assess: (1) whether the circuit connecting amygdala, CEA, and DA cells follows CEA intrinsic organization, or a more direct topography involving bed nucleus vs central nucleus divisions; (2) CRF content of the CEA-DA path; and (3) striatal subregions specifically involved in CEA-DA-striatal loops. We found that the amygdala-CEA-DA path follows macrostructural subdivisions, with the majority of input/outputs converging in the medial central nucleus, the sublenticular extended amygdala, and the posterior lateral bed nucleus of the stria terminalis. The proportion of CRF+ outputs is >50%, and mainly targets the A10 parabrachial pigmented nucleus (PBP) and A8 (retrorubal field, RRF) neuronal subpopulations, with additional inputs to the dorsal A9 neurons. CRF-enriched CEA-DA projections are positioned to influence outputs to the ‘limbic-associative’ striatum, which is distinct from striatal regions targeted by DA cells lacking CEA input. We conclude that the concept of the CEA is supported on connectional grounds, and that CEA termination over the PBP and RRF neuronal populations can influence striatal circuits involved in associative learning.