Monday, October 27, 2014

Evidence-Based Assessment of Well-Established Interventions: The Parachute and the Epidural Hematoma

Evidence-Based Assessment of Well-Established Interventions: The Parachute and the Epidural Hematoma
Neurosurgery - Current Issue

imageBACKGROUND: The methods of evidence-based medicine are a relatively recent development in the understanding of clinical practice. They are criticized as not providing support for interventions long held to be highly effective based on experience that predated the availability of evidence-based analysis. OBJECTIVE: To determine if the methods of evidence-based medicine can be successfully applied to interventions established before those methods were developed. METHODS: Systematic review of English language literature on the natural history and treated prognosis of acute epidural hematoma and analysis of existing data on mortality associated with parachute use. DATA SOURCES: Sources of data included Medline, Old Medline, Science Citation Index, British and US Parachute Associations, and Federal Aviation Administration and National Transportation Safety Board databases (both of the United States). Also included were national databases reporting mortality and total number of parachute uses. RESULTS: The estimated mortality of falling from an airplane with an ineffective parachute is 74% (69-79). Mortality associated with effective parachute deployment is between 0.0011% and 0.0017%. For acute epidural hematoma, estimated mortality is 98.54% (95.1-99.9) without treatment and 12.9% (10.5-15.3) with treatment. The number needed to treat to prevent 1 death for the parachute is estimated to be 1.35 (1.27-1.45) and for epidural hematoma 1.17 (1.13-1.22) (95% binomial confidence intervals in parentheses). CONCLUSION: The methods of evidence-based medicine are robust and can deal with interventions of great face validity and those considered well established before such methods were well developed. We propose initial criteria for evaluating the quality of evidence supporting long-established interventions. ABBREVIATIONS: ARR, absolute risk reduction CI, confidence interval EC-IC, extracranial-intracranial FAA, Federal Aviation Administration NNT, number needed to treat NTSB, National Transportation Safety Board RCT, randomized clinical trial.

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/11000/Evidence_Based_Assessment_of_Well_Established.9.aspx

Surgery of Intradural Extramedullary Tumors: Retrospective Analysis of 107 Cases

Surgery of Intradural Extramedullary Tumors: Retrospective Analysis of 107 Cases
Neurosurgery Blog

Tarantino, Roberto MD*; Donnarumma, Pasquale MD*; Nigro, Lorenzo MD*; Rullo, Marika PhD‡; Santoro, Antonio MD*; Delfini, Roberto MD*
*Department of Neurology and Psychiatry, Division of Neurosurgery, and

‡Department of Psychology of Developmental and Socialization Processes, Sapienza University of Rome, Rome, Italy

BACKGROUND: Intradural extramedullary tumors (IDEMTs) are uncommon lesions that cause pain and neurological deficits.

OBJECTIVE: To evaluate the effects of surgery for IDEMTs.

METHODS: This cohort study recruited all patients operated on for IDEMTs at the Department of Neurology and Psychiatry of Sapienza University of Rome from January 2003 to January 2013. The analysis was conducted on clinical records evaluation over a 1-year follow-up. The Graphic Rating Scale was used to assess pain. Neurological deficits were detected through neurological examination. Quality of life was evaluated with the EuroQol (EQ-5D). Statistical interpretation of the data was performed with SPSS version 19 software.

RESULTS: One hundred seven patients were recruited. Three were lost to follow-up. Patients reported lower level of pain 1 year after surgery (before surgery, 6.05; after surgery, 3.65). Mean comparison showed a significant decrease of −2.400 (P < .001). Ninety-two patients (88.5%) were neurologically asymptomatic 1 year after surgery. Only 12 patients (11.5%) presented with a deficit, with a global decrease of 39% (χ2 = 27.6; P < .005). The quality of life in patients was middle to high (mean rating of EQ-5D visual analog score, 61.78%). The lowest levels of quality of life were found in patients with sphincter dysfunctions (mean, 33.4).

CONCLUSION: Surgery for IDEMTs has a good outcome. Patients reported lower levels of pain and a drastic reduction in neurological symptoms 1 year after surgery. The quality of life is middle to high. It is influenced mainly by the neurological outcome.

http://journals.lww.com/neurosurgery/Fulltext/2014/11000/Surgery_of_Intradural_Extramedullary_Tumors__.3.aspx

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Original Article: http://neurocirurgiabr.com/surgery-of-intradural-extramedullary-tumors-retrospective-analysis-of-107-cases/?utm_source=rss&utm_medium=rss&utm_campaign=surgery-of-intradural-extramedullary-tumors-retrospective-analysis-of-107-cases

Reoperation for Recurrent High-Grade Glioma: A Current Perspective of the Literature

Reoperation for Recurrent High-Grade Glioma: A Current Perspective of the Literature
Neurosurgery - Most Popular Articles

image Optimal treatment for recurrent high-grade glioma continues to evolve. Currently, however, there is no consensus in the literature on the role of reoperation in the management of these patients. In this analysis, we reviewed the literature to examine the role of reoperation in patients with World Health Organization grade III or IV recurrent gliomas, focusing on how reoperation affects outcome, perioperative complications, and quality of life. An extensive literature review was performed through the use of the PubMed and Ovid Medline databases for January 1980 through August 2013. A total 31 studies were included in the final analysis. Of the 31 studies with significant data from single or multiple institutions, 29 demonstrated a survival benefit or improved functional status after reoperation for recurrent high-grade glioma. Indications for reoperation included new focal neurological deficits, tumor mass effect, signs of elevated intracranial pressure, headaches, increased seizure frequency, and radiographic evidence of tumor progression. Age was not a contraindication to reoperation. Time interval of at least 6 months between operations and favorable performance status (Karnofsky Performance Status score ≥70) were important predictors of benefit from reoperation. Extent of resection at reoperation improved survival, even in patients with subtotal resection at initial operation. Careful patient selection such as avoiding those individuals with poor performance status and bevacizumab within 4 weeks of surgery is important. Although limited to retrospective analysis and patient selection bias, mounting evidence suggests a survival benefit in patients receiving a reoperation at the time of high-grade glioma recurrence. ABBREVIATIONS: EOR, extent of resection GTR, gross total resection KPS, Karnofsky Performance Status STR, subtotal resection WHO, World Health Organization

Original Article: http://journals.lww.com/neurosurgery/Fulltext/2014/11000/Reoperation_for_Recurrent_High_Grade_Glioma___A.1.aspx

Surgical Site Infections in Spine Surgery: Identification of Microbiologic and Surgical Characteristics in 239 Cases

Surgical Site Infections in Spine Surgery: Identification of Microbiologic and Surgical Characteristics in 239 Cases
Neurosurgery Blog

Surgical Site Infections in Spine Surgery: Identification of Microbiologic and Surgical Characteristics in 239 Cases

Abdul-Jabbar, Amir MD*; Berven, Sigurd H. MD; Hu, Serena S. MD; Chou, Dean MD; Mummaneni, Praveen V. MD; Takemoto, Steven PhD; Ames, Christopher MD; Deviren, Vedat MD; Tay, Bobby MD; Weinstein, Phil MD; Burch, Shane MD; Liu, Catherine MD§

Study Design. Retrospective analysis.

Objective. The objective of this study was to describe the microbiology of surgical site infection (SSI) in spine surgery and relationship with surgical management characteristics.

Summary of Background Data. SSI is an important complication of spine surgery that results in significant morbidity. A comprehensive and contemporary understanding of the microbiology of postoperative spine infections is valuable to direct empiric antimicrobial treatment and prophylaxis and other infection prevention strategies.

Methods. All cases of spinal surgery associated with SSI between July 2005 and November 2010 were identified by the hospital infection control surveillance program using Centers for Disease Control National Health Safety Network criteria. Surgical characteristics and microbiologic data for each case were gathered by direct medical record review.

Results. Of 7529 operative spine cases performed between July 2005 and November 2010, 239 cases of SSI were identified. The most commonly isolated pathogen was Staphylococcus aureus (45.2%), followed by Staphylococcus epidermidis (31.4%). Methicillin-resistant organisms accounted for 34.3% of all SSIs and were more common in revision than in primary surgical procedures (47.4% vs. 28.0%, P = 0.003). Gram-negative organisms were identified in 30.5% of the cases. Spine surgical procedures involving the sacrum were significantly associated with gram-negative organisms (P < 0.001) and polymicrobial infections (P = 0.020). Infections due to gram-negative organisms (P = 0.002) and Enterococcus spp. (P = 0.038) were less common in surgical procedures involving the cervical spine. Cefazolin-resistant gram-negative organisms accounted for 61.6% of all gram-negative infections and 18.8% of all SSIs.

Conclusion. Although gram-positive organisms predominated, gram-negative organisms accounted for a sizeable portion of SSI, particularly among lower lumbar and sacral spine surgical procedures. Nearly half of infections in revision surgery were due to a methicillin-resistant organism. These findings may help guide choice of empiric antibiotics while awaiting culture data and antimicrobial prophylaxis strategies in specific spine surgical procedures.

http://journals.lww.com/spinejournal/Abstract/2013/10150/Surgical_Site_Infections_in_Spine_Surgery_.15.aspx

The post Surgical Site Infections in Spine Surgery: Identification of Microbiologic and Surgical Characteristics in 239 Cases appeared first on NEUROSURGERY BLOG.



Original Article: http://neurocirurgiabr.com/surgical-site-infections-in-spine-surgery-identification-of-microbiologic-and-surgical-characteristics-in-239-cases/?utm_source=rss&utm_medium=rss&utm_campaign=surgical-site-infections-in-spine-surgery-identification-of-microbiologic-and-surgical-characteristics-in-239-cases

Can Viruses Treat Cancer?

Can Viruses Treat Cancer?
Scientific American: Mind and Brain

For some cancer patients, viruses engineered to zero in on tumor cells work like a wonder drug. The task now is to build on this success

-- Read more on ScientificAmerican.com


Original Article: http://www.scientificamerican.com/article/can-viruses-treat-cancer/

Breast cancer in Wilms tumor survivors: New insights into primary and secondary prevention

Breast cancer in Wilms tumor survivors: New insights into primary and secondary prevention
Cancer

Pediatric oncology providers should closely evaluate their female survivors of Wilms tumor for risk factors for the development of breast cancer, including chest radiography (even at doses <20 gray), age >10 years at the time of Wilms tumor diagnosis, and, possibly, radiotherapy to the flank. Those patients deemed to be at high risk should undergo breast cancer surveillance with mammography, breast magnetic resonance imaging, or both starting at age 25 years.



Original Article: http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1002/cncr.28906

Newman's Notes: Alteplase for Ischemic Stroke (CME/CE)

Newman's Notes: Alteplase for Ischemic Stroke (CME/CE)
MedPage Today Neurology

(MedPage Today) -- Meta-analyses of alteplase for ischemic stroke debunked for high or unreported heterogeneity.

Original Article: http://www.medpagetoday.com/Cardiology/Strokes/48256

Teaching NeuroImages: Massive cerebral edema after CT myelography: An optical illusion

Teaching NeuroImages: Massive cerebral edema after CT myelography: An optical illusion
Neurology recent issues

A 74-year-old woman underwent myelography with iohexol to exclude a CSF leak. Three days later, her son noticed mild facial asymmetry and took her back to the hospital. Neurologic status was at baseline except for minimal left nasolabial flattening. Initial head CT appeared to show diffuse cerebral edema (figure, A), but the following morning the appearance had normalized (figure, B). Based on the spontaneous clinicoradiologic improvement, we hypothesize that an illusion of cerebral edema was caused by residual iohexol. Although not reported with iohexol, older agents can cause hyperdense gray matter and can accumulate in sulci.1



Original Article: http://www.neurology.org/cgi/content/short/83/18/e170?rss=1

The 10-year anniversary of the Neurology Resident & Fellow Section: 2004-2014

The 10-year anniversary of the Neurology Resident & Fellow Section: 2004-2014
Neurology recent issues

Over the past 10 years, the Neurology® Resident & Fellow Section (RFS) has served as an outlet for articles and other journal-related activities relevant to trainees. The RFS was founded in 2004 by Drs. Karen Johnston and Robert Griggs with a focus on academic topics such as training, practice, ethics, teaching, and international training experiences.1 The initial goals were met and superseded as subsections have gradually evolved to cover current areas, including Emerging Subspecialties in Neurology, Clinical Reasoning, Right Brain, Child Neurology, Pearls & Oy-sters, International Issues, Education Research and Initiatives, Teaching NeuroImages (including both static images and videos), and Media and Book Reviews. In addition, submissions have grown in number and quality from 12 in 2004 to 481 in 2013, with a current acceptance rate at approximately 30% (figure). A full listing of the different subsections and other activities of the RFS can be found at http://www.neurology.org/site/feature/index.xhtml. Two excellent examples of articles from the RFS can be found in this issue of Neurology.



Original Article: http://www.neurology.org/cgi/content/short/83/18/1586?rss=1

Wednesday, October 22, 2014

Error in Intensive Care: Psychological Repercussions and Defense Mechanisms Among Health Professionals

Error in Intensive Care: Psychological Repercussions and Defense Mechanisms Among Health Professionals
Critical Care Medicine - Current Issue

imageObjective: To identify the psychological repercussions of an error on professionals in intensive care and to understand their evolution. To identify the psychological defense mechanisms used by professionals to cope with error. Design: Qualitative study with clinical interviews. We transcribed recordings and analysed the data using an interpretative phenomenological analysis. Setting: Two ICUs in the teaching hospitals of Besançon and Dijon (France). Subjects: Fourteen professionals in intensive care (20 physicians and 20 nurses). Interventions: None. Measurements and Main Results: We conducted 40 individual semistructured interviews. The participants were invited to speak about the experience of error in ICU. The interviews were transcribed and analyzed thematically by three experts. In the month following the error, the professionals described feelings of guilt (53.8%) and shame (42.5%). These feelings were associated with anxiety states with rumination (37.5%) and fear for the patient (23%); a loss of confidence (32.5%); an inability to verbalize one's error (22.5%); questioning oneself at a professional level (20%); and anger toward the team (15%). In the long term, the error remains fixed in memory for many of the subjects (80%); on one hand, for 72.5%, it was associated with an increase in vigilance and verifications in their professional practice, and on the other hand, for three professionals, it was associated with a loss of confidence. Finally, three professionals felt guilt which still persisted at the time of the interview. We also observed different defense mechanisms implemented by the professional to fight against the emotional load inherent in the error: verbalization (70%), developing skills and knowledge (43%), rejecting responsibility (32.5%), and avoidance (23%). We also observed a minimization (60%) of the error during the interviews. Conclusions: It is important to take into account the psychological experience of error and the defense mechanisms developed following an error because they appear to determine the professional's capacity to acknowledge and disclose his/her error and to learn from it.

Original Article: http://journals.lww.com/ccmjournal/Fulltext/2014/11000/Error_in_Intensive_Care___Psychological.7.aspx