Glioblastoma is the most common and aggressive malignant primary brain tumor. Cellular heterogeneity is a characteristic feature of the disease and contributes to the difficulty in formulating effective therapies. Glioma stem-like cells (GSCs) have been identified as a subpopulation of tumor cells that are thought to be largely responsible for resistance to treatment. Intratumoral hypoxia contributes to maintenance of the GSCs by supporting the critical stem cell traits of multipotency, self-renewal, and tumorigenicity. This review highlights the interaction of GSCs with the hypoxic tumor microenvironment, exploring the mechanisms underlying the contribution of GSCs to tumor vessel dynamics, immune modulation, and metabolic alteration.

OBJECTIVENutritional deficiency negatively affects outcomes in many health conditions. In spine surgery, evidence linking preoperative nutritional deficiency to postoperative surgical site infection (SSI) has been limited to small retrospective studies. Authors of the current study analyzed a large consecutive cohort of patients who had undergone elective spine surgery to determine the relationship between a serum biomarker of nutritional status (preoperative prealbumin levels) and SSI.METHODSThe authors conducted a retrospective review of the electronic medical charts of patients who had undergone posterior spinal surgeries and whose preoperative prealbumin level was available. Additional data pertinent to the risk of SSI were also collected. Patients who developed a postoperative SSI were identified, and risk factors for postoperative SSI were analyzed. Nutritional deficiency was defined as a preoperative serum prealbumin level ≤ 20 mg/dl.RESULTSAmong a consecutive series of 387 patients who met the study criteria for inclusion, the infection rate for those with preoperative prealbumin ≤ 20 mg/dl was 17.8% (13/73), versus 4.8% (15/314) for those with preoperative prealbumin > 20 mg/dl. On univariate and multivariate analysis a low preoperative prealbumin level was a risk factor for postoperative SSI with a crude OR of 4.29 (p < 0.01) and an adjusted OR of 3.28 (p = 0.02). In addition, several previously known risk factors for infection, including diabetes, spinal fusion, and number of operative levels, were significant for the development of an SSI.CONCLUSIONSIn this consecutive series, preoperative prealbumin levels, a serum biomarker of nutritional status, correlated with the risk of SSI in elective spine surgery. Prehabilitation before spine surgery, including strategies to improve nutritional status in patients with nutritional deficiencies, may increase value and improve spine care.

Patients with drug‐resistant epilepsy (DRE) rarely achieve seizure freedom with medical therapy alone. Despite being safe and effective for select patients with DRE, epilepsy surgery remains heavily underutilized. Multiple studies have indicated that the overall rates of surgery in patients with DRE have stagnated in recent years and may be decreasing, even when hospitalizations for epilepsy‐related problems are on the rise. Ultimately, many patients with DRE who might otherwise benefit from surgery continue to have intractable seizures, lacking access to the full spectrum of available treatment options. In this article, we review the various factors accounting for the persistent underutilization of epilepsy surgery and uncover several key themes, including the persistent knowledge gap among physicians in identifying potential surgical candidates, lack of coordinated patient care, patient misconceptions of surgery, and socioeconomic disparities impeding access to care. Moreover, factors such as the cost and complexity of the preoperative evaluation, a lack of federal resource allocation for the research of surgical therapies for epilepsy, and difficulties recruiting patients to clinical trials all contribute to this multifaceted dilemma.