Saturday, June 30, 2012

Coerção para citar, mais um desvio do fator de impacto

É verdade que algumas revistas científicas, em maior ou menor grau, "sugerem" aos autores que citem artigos previamente publicados nestes periódicos? Parece meio esdrúxulo, mas os exemplos se ampliam. A causa deste comportamento? Os editores querem aumentar o fator de impacto das revistas. As revistas com maior impacto tendem a receber os artigos de melhor qualidade.

Como avaliar o mérito de





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Hemorrhage and risk of further hemorrhagic strokes following cerebral revascularization in Moyamoya

Robert W. J. Ryan, Abhineet Chowdhary, Gavin W Britz

Surgical Neurology International 2012 3(1):72-72

Background: We sought to review the current literature with regards to future risks of hemorrhage following cerebral revascularization in Moyamoya disease (MMD). Methods: We performed a comprehensive literature review using PubMed to inspect the available data on the risk of hemorrhage after revascularization in MMD. Results: In this review, we identify the risk factors associated with hemorrhage in MMD both before and after cerebral revascularization. We included proposed pathophysiology of the hemorrhagic risk, role of the type of bypass performed, treatment options, and future needs for investigation. Conclusions: The published cases and series of MMD treatment do show a risk of hemorrhage after treatment with either direct or indirect bypass both in the immediate as well as long-term future. While there are no discernible patterns in the rate of these hemorrhages, there is Class III evidence for the predictive effect of multiple microbleeds on preoperative imaging. Also, whereas revascularization, both direct and indirect, has been shown to reduce ischemic complications from MMD, there is not an association with the risk of hemorrhage after the procedure. Further studies need to be performed to help evaluate what the risk factors are and how to counsel patients as to the long-term outlook of this disease process.





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Unruptured Cerebral Aneurysms: Size, Shape, Location Matter

A large Japanese study provides new information on the natural course of unruptured cerebral aneurysms and pinpoints specific risk factors for rupture.
Medscape Medical News





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Management of non-traumatic intraventricular hemorrhage

Abstract  
Intraventricular hemorrhage (IVH) is defined as the eruption of blood in the cerebral ventricular system and is mostly secondary to spontaneous intracerebral hemorrhage and aneurysmal and arteriovenous malformation rupture. IVH is a proven risk factor of increased mortality and poor functional outcome. Its seriousness is correlated not only with the amount of blood but also with the involvement of the third and fourth ventricles. There are four mechanisms that explain the pathophysiology of this event: acute obstructive hydrocephalus, the mass effect exerted by the blood clot, the toxicity of blood-breaking products on the adjacent brain parenchyma, and, lastly, the development of a chronic hydrocephalus. It is thus obvious that the clearance of blood from the ventricles should be a therapeutic goal. In cases of acute hydrocephalus, external ventricular drainage is a mandatory step, but proven often insufficient. The concomitant use of intraventricular fibrinolytics such as recombinant tissue plasminogen activator or urokinase seems to be beneficial at least in the context of spontaneous intracerebral hemorrhage, in which their use is now accepted but not yet validated by a randomized trial. Given the potential neurotoxicity of these agents, further research is needed in order to identify the best treatment for intraventricular fibrinolysis (IVF). The endoscopic retrieval of intraventricular blood was also described recently and seems to be as efficient as IVF, but its use is limited to specialized centers. IVH represents a therapeutic challenge for neurosurgeons, neurologists, and intensivists. Thus, a better understanding of this dramatic event will help in better tailoring the treatment strategies.

  • Content Type Journal Article
  • Category Review
  • Pages 1-11
  • DOI 10.1007/s10143-012-0399-9
  • Authors
    • Thomas Gaberel, Department of Neurosurgery, Caen University Hospital, Avenue de la Cote de Nacre, Caen, 14000 France
    • Christian Magheru, Department of Neurosurgery, Caen University Hospital, Avenue de la Cote de Nacre, Caen, 14000 France
    • Evelyne Emery, Department of Neurosurgery, Caen University Hospital, Avenue de la Cote de Nacre, Caen, 14000 France





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Thursday, June 28, 2012

Seizure-free and neuropsychological outcomes after temporal lobectomy with amygdalohippocampectomy i

Journal of Neurosurgery: Pediatrics, Volume 0, Issue 0, Page 1-5, Ahead of Print.
Object Temporal lobe epilepsy is an uncommon clinical syndrome in the pediatric population. The most common underlying pathologies include low-grade gliomas, cortical dysplasia, and, less commonly, hippocampal sclerosis (HS). There is a paucity of data on neuropsychological and seizure-free outcomes in these patients after temporal lobectomy. In this study, the authors reviewed their seizure-free and neuropsychological outcomes after temporal lobectomy for pediatric HS. Methods The authors retrospectively reviewed the medical records of pediatric patients with HS who underwent anterior temporal lobectomy and amygdalohippocampectomy between 1998 and 2011 at the Cleveland Clinic. Results of neuropsychological assessment before and after surgery and seizure-free outcome at last follow-up were obtained. Results Forty-five patients met the inclusion criteria. Thirty-four (76%) patients had pathology of HS alone and 10 (22%) had HS and cortical dysplasia. The mean duration of follow-up was 60.2 months. Eighty-four percent of patients had postoperative Engel Class I or II outcomes. Neuropsychological outcomes remained unchanged or minimally improved postoperatively. Conclusions Seizure-free outcomes in pediatric HS are similar to historical rates in adult HS. Neuropsychological assessments remain stable after temporal lobectomy. Standard temporal lobectomy should be considered in pediatric patients with medically intractable epilepsy secondary to HS.










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CNPq divulga diretrizes básicas para integridade na atividade científica

Confira abaixo as diretrizes básicas para a integridade na atividade científica:



O autor deve sempre dar crédito a todas as fontes que fundamentam diretamente seu trabalho.
Toda citação in verbis de outro autor deve ser colocada entre aspas.
Quando se resume um texto alheio, o autor deve procurar reproduzir o significado exato das idéias ou fatos apresentados pelo autor original, que deve





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What happened to the doctor-patient relationship?

bmj;344/jun25_1/e4349/FIG1F1fig1An old maxim of general practice says that doctors get the patients they deserve, because patients actively seek out like-minded doctors who share their own health...





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Wednesday, June 27, 2012

Evidenced based practice should reduce overdiagnosis and overtreatment

Overdiagnosis can result from failure to practise evidence based medicine properly.1 The positive result of any screening test should be dealt with in the same way as a presenting symptom, by...





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Neurons That Impact On Appetite Also Linked To Cocaine Desire

People who have higher appetites for food tend to have lower interest in cocaine, or exploratory behavior, while those less interested in foods may become increasingly interested in cocaine, because of the way some neurons in part of the brain that controls hunger work, researchers from Yale University School of Medicine reported in Nature Neuroscience...





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Moyamoya Disease-Related Versus Primary Intracerebral: Hemorrhage Location and Outcomes Are Differen

Background and Purpose—

The purpose of our study was to compare lesion location between moyamoya disease-related intracerebral hemorrhage (MMD-ICH) and primary intracerebral hemorrhage (P-ICH).

Methods—

Ninety-three patients each with MMD-ICH and P-ICH were compared. In patients with MMD-ICH, angiographic findings were assessed with special attention to the prominent anterior choroidal artery. Follow-up data were obtained through clinical visit and telephone interview.

Results—

The location of hemorrhage was different between MMD-ICH and P-ICH, the most frequent one being intraventricular region (37.6%) in the former and putaminal region (46.2%) in the latter (P<0.001). Intraventricular hemorrhage was more frequent in MMD-ICH than P-ICH (80.6% versus 20.4%, P<0.001). In MMD-ICH, primary intraventricular hemorrhage was more closely associated with prominent ipsilateral anterior choroidal artery than ICHs without intraventricular hemorrhage (75.0% versus 16.7%, P<0.001). Higher rates of rebleeding and infarction were observed in MMD-ICH than in age- and sex-matched patients with P-ICH.

Conclusions—

MMD-ICH may differ from P-ICH in hemorrhage location, generally presenting with intraventricular hemorrhage with or without ICH, which may be due to a prominent anterior choroidal artery. Patients with MMD may be more likely to experience recurrent bleeding and infarction.






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Impact of Atrial Fibrillation on Outcome in Thrombolyzed Patients With Stroke: Evidence From the Vir

Background and Purpose—

Atrial fibrillation has been considered a risk factor for poor outcome from acute stroke and may influence response to thrombolysis, although supporting data are limited due to potential confounding with age and stroke severity.

Method—

We assessed the association of atrial fibrillation and thrombolysis exposure with the modified Rankin Scale score distribution at 90 days among patients registered in a trials archive. We used an age and baseline National Institutes of Health Stroke Scale-adjusted Cochran-Mantel-Haenszel test to test significance (P) followed by proportional odds logistic regression analysis to estimate the ORs for improved modified Rankin Scale score.

Results—

Data were available for 7091 patients, of whom 3027 were thrombolyzed. A total of 1631 patients had a history of atrial fibrillation, of whom 639 were thrombolyzed. Among patients with atrial fibrillation, baseline severity was greater (median baseline National Institutes of Health Stroke Scale, 14 versus 12; P<0.001) and age was higher (mean age, 74.0 versus 66.5; P<0.001). An association of treatment with outcome was seen independently and was of similar magnitude within patients with atrial fibrillation (OR, 1.44; 95% CI, 1.12–1.73; P<0.001) and without atrial fibrillation (OR, 1.53; 95% CI, 1.39–1.69; P<0.001). No association of atrial fibrillation and overall stroke outcome could be found (OR, 0.93; 95% CI, 0.84–1.03; P=0.409).

Conclusion—

In this nonrandomized comparison, presence of atrial fibrillation had no independent impact on stroke outcome and compared with untreated comparators, the patients who received thrombolysis experienced an advantage in outcomes that was of equal magnitude whether in the presence or absence of atrial fibrillation.






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Intracranial Carotid Artery Atherosclerosis: Prevalence and Risk Factors in the General Population [

Background and Purpose—

Intracranial atherosclerosis is worldwide one of the leading causes of stroke. However, surprisingly little is known about its prevalence and risk factors in a community-dwelling population of white descent. In this study, we determined the prevalence and investigated risk factors of intracranial internal carotid artery calcification (ICAC) as a marker of intracranial atherosclerosis.

Methods—

To quantify the volume of ICAC, 2495 participants (mean age, 69.6 years) from the population-based Rotterdam Study underwent a nonenhanced computed tomography of the intracranial internal carotid arteries. We calculated the prevalence of ICAC. Next, we defined sex-specific quartiles and defined the upper quartile as severe ICAC. Risk factors of ICAC were investigated by linear and logistic multivariate modeling and were stratified by sex.

Results—

The overall prevalence of ICAC was 82.2%. The median volume of ICAC was 44 mm3 and was larger in men. Age was independently associated with ICAC in both men and women. In men, excessive alcohol intake and smoking (OR, 1.74 [95% CI, 1.28–2.37] and 1.72 [95% CI, 1.10–2.70]) were strong risk factors of ICAC, whereas diabetes and hypertension were in women (OR, 2.02 [95% CI, 1.29–3.17] and 1.79 [95% CI, 1.20–2.68]). A low high-density-lipoprotein concentration was not associated with ICAC.

Conclusions—

ICAC is highly prevalent and occurs in over 80% of older, white persons. Conventional cardiovascular risk factors are associated with ICAC, but risk factor profiles differ between men and women.






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Effects of Repetitive Transcranial Magnetic Stimulation on Motor Functions in Patients With Stroke:

Background and Purpose—

The purpose of this study was to perform a meta-analysis of studies that investigated the effects of repetitive transcranial magnetic stimulation (rTMS) on upper limb motor function in patients with stroke.

Methods—

We searched for randomized controlled trials published between January 1990 and October 2011 in PubMed, Medline, Cochrane, and CINAHL using the following key words: stroke, cerebrovascular accident, and repetitive transcranial magnetic stimulation. The mean effect size and a 95% CI were estimated for the motor outcome and motor threshold using fixed and random effect models.

Results—

Eighteen of the 34 candidate articles were included in this analysis. The selected studies involved a total of 392 patients. A significant effect size of 0.55 was found for motor outcome (95% CI, 0.37–0.72). Further subgroup analyses demonstrated more prominent effects for subcortical stroke (mean effect size, 0.73; 95% CI, 0.44–1.02) or studies applying low-frequency rTMS (mean effect size, 0.69; 95% CI, 0.42–0.95). Only 4 patients of the 18 articles included in this analysis reported adverse effects from rTMS.

Conclusions—

rTMS has a positive effect on motor recovery in patients with stroke, especially for those with subcortical stroke. Low-frequency rTMS over the unaffected hemisphere may be more beneficial than high-frequency rTMS over the affected hemisphere. Recent limited data suggest that intermittent theta-burst stimulation over the affected hemisphere might be a useful intervention. Further well-designed studies in a larger population are required to better elucidate the differential roles of various rTMS protocols in stroke treatment.






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Poor Prognosis in Warfarin-Associated Intracranial Hemorrhage Despite Anticoagulation Reversal [Orig

Background and Purpose

Anticoagulant-associated intracranial hemorrhage (aaICH) presents with larger hematoma volumes, higher risk of hematoma expansion, and worse outcome than spontaneous intracranial hemorrhage. Prothrombin complex concentrates (PCCs) are indicated for urgent reversal of anticoagulation after aaICH. Given the lack of randomized controlled trial evidence of efficacy, and the potential for thrombotic complications, we aimed to determine outcomes in patients with aaICH treated with PCC.

Methods

We conducted a prospective multicenter registry of patients treated with PCC for aaICH in Canada. Patients were identified by local blood banks after the release of PCC. A chart review abstracted clinical, imaging, and laboratory data, including thrombotic events after therapy. Hematoma volumes were measured on brain CT scans and primary outcomes were modified Rankin Scale at discharge and in-hospital mortality.

Results

Between 2008 and 2010, 141 patients received PCC for aaICH (71 intraparenchymal hemorrhages). The median age was 78 years (interquartile range, 14), 59.6% were male, and median Glasgow Coma Scale was 14. Median international normalized ratio was 2.6 (interquartile range, 2.0) and median parenchymal hematoma volume was 15.8 mL (interquartile range, 31.8). Median post-PCC therapy international normalized ratio was 1.4: 79.5% of patients had international normalized ratio correction (<1.5) within 1 hour of PCC therapy. Patients with intraparenchymal hemorrhage had an in-hospital mortality rate of 42.3% with median modified Rankin Scale of 5. Significant hematoma expansion occurred in 45.5%. There were 3 confirmed thrombotic complications within 7 days of PCC therapy.

Conclusions

PCC therapy rapidly corrected international normalized ratio in the majority of patients, yet mortality and morbidity rates remained high. Rapid international normalized ratio correction alone may not be sufficient to alter prognosis after aaICH.






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Association Between Changes in Lipid Profiles and Progression of Symptomatic Intracranial Atheroscle

Background and Purpose—

Predictors of progression of intracranial atherosclerotic stenosis have not been clearly identified. We investigated whether poststroke changes in lipid profiles would affect the prognosis of symptomatic intracranial atherosclerotic stenosis.

Methods—

This is a substudy of Trial of cilOstazol in Symptomatic intracranial Stenosis 2 (TOSS-2). From 10 centers we enrolled 230 subjects with acute symptomatic stenosis in the M1 segment of the middle cerebral artery or basilar artery. At baseline and 7 months after stroke, subjects underwent MR angiogram and assessment of cardiovascular risk factors including lipoprotein levels. Progression of intracranial atherosclerotic stenosis was determined by comparing stenosis on the baseline and follow-up MR angiograms.

Results—

Cilostazol treatment was more frequently seen in the nonprogression group (109 of 198 [55.1%]) than in the progression group (11 of 32 [34.4%]). At 7 months after stroke when compared with baseline, low-density lipoprotein cholesterol and total cholesterol levels decreased in both groups. However, only nonprogressors showed increase in high-density lipoprotein cholesterol levels between baseline and follow-up. Changes in apolipoprotein B/apolipoprotein A-I levels were not different between the groups, although apolipoprotein B/A-I at 7 months was higher in progressors than in nonprogressors. Remnant lipoprotein cholesterol levels decreased in nonprogressors, whereas they did not change in progressors. In multivariable analyses, after adjusting for cilostazol treatment and remnant lipoprotein cholesterol reduction or apolipoprotein B/A-I at 7 months, high-density lipoprotein cholesterol elevation remained as a significant predictor for the nonprogression.

Conclusions—

This is the first prospective multicenter study to demonstrate that high-density lipoprotein cholesterol elevation, along with remnant lipoprotein cholesterol reduction and low apolipoprotein B/A-I, is associated with prevention of angiographic progression of symptomatic intracranial atherosclerotic stenosis.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00130039.






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Thirty-Day Mortality After Ischemic Stroke and Intracranial Hemorrhage in Patients With Atrial Fibri

Background and Purpose—

Prescribing warfarin for atrial fibrillation depends in large part on the expected reduction in ischemic stroke risk versus the expected increased risk of intracranial hemorrhage (ICH). However, the anticoagulation decision also depends on the relative severity of such events. We assessed the impact of anticoagulation on 30-day mortality from ischemic stroke versus ICH in a large community-based cohort of patients with atrial fibrillation.

Methods—

We followed 13 559 patients with atrial fibrillation enrolled in an integrated healthcare delivery system for a median 6 years. Incident ischemic strokes and ICHs were identified from computerized databases and validated through medical record review. The association of warfarin and international normalized ratio at presentation with 30-day mortality was modeled using multivariable logistic regression adjusting for clinical factors.

Results—

We identified 1025 incident ischemic strokes and 299 ICHs during follow-up. Compared with no antithrombotic therapy, warfarin was associated with reduced Rankin score and lower 30-day mortality from ischemic stroke (adjusted OR, 0.64; 95% CI, 0.45–0.91) but a higher mortality from ICH (OR, 1.62; 95% CI, 0.88–2.98). Therapeutic international normalized ratios (2–3) were associated with an especially low ischemic stroke mortality (OR, 0.38; 95% CI, 0.20–0.70), whereas international normalized ratios >3 increased the odds of dying of ICH by 2.66-fold (95% CI, 1.21–5.86).

Conclusions—

Warfarin reduces 30-day mortality from ischemic stroke but increases ICH-related mortality. Both effects on event severity as well as on event rates need to be incorporated into rational decision-making about anticoagulants for atrial fibrillation.






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Carotid Endarterectomy in Asymptomatic Patients With Limited Life Expectancy [Original Contributions

Background and Purpose

Data from randomized trials assert that asymptomatic patients undergoing carotid endarterectomy (CEA) must live 3 to 5 years to realize the benefit of surgery. We examined how commonly CEA is performed among asymptomatic patients with limited life expectancy.

Methods

Within the American College of Surgeons National Quality Improvement Project we identified 8 conditions associated with limited life expectancy based on survival estimates using external sources. We then compared rates of 30-day stroke, death, and myocardial infarction after CEA between asymptomatic patients with and without life-limiting conditions.

Results

Of 12 631 CEAs performed in asymptomatic patients, 2525 (20.0%) were in patients with life-limiting conditions or diagnoses. The most common conditions were severe chronic obstructive pulmonary disease and American Society of Anesthesiologists Class IV designation. Patients with life-limiting conditions had significantly higher rates of perioperative complications, including stroke (1.8% versus 0.9%, P<0.001), death (1.4% versus 0.3%, P<0.001), and stroke/death (2.9% versus 1.1%, P<0.001). Even after adjustment for other comorbidities, patients with life-limiting conditions were nearly 3 times more likely to experience perioperative stroke or death than those without these conditions (OR, 2.8; 95% CI, 2.1–3.8; P<0.001).

Conclusion

CEA is performed commonly in asymptomatic patients with life-limiting conditions. Given the high rates of postoperative stroke/death in these patients as well as their limited life expectancy, the net benefit of CEA in this population remains uncertain. Health policy research examining the role of CEA in asymptomatic patients with life-limiting conditions is necessary and may serve as a potential source for significant healthcare savings in the future.






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iPad Risky for Hydrocephalus Shunt Valves (CME/CE)

(MedPage Today) -- Getting too close to an iPad 2 may cause magnetically set shunt valves to malfunction, researchers found.





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tPA Safe in Stroke Patients on Warfarin (CME/CE)

(MedPage Today) -- Patients who were taking warfarin had no increased risk of symptomatic intracranial hemorrhage after treatment with intravenous tissue plasminogen activator (tPA), a large observational study showed.





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Programmable shunt valve affected by exposure to a tablet computer

Journal of Neurosurgery: Pediatrics, Volume 0, Issue 0, Page 1-3, Ahead of Print.
Object The authors investigated the effect of a tablet computer on performance-level settings of a programmable shunt valve. Methods Magnetic field strength near the tablet computer with and without a cover was recorded at distances between 0 and 100 mm. Programmable valves were exposed to the tablet device at distances of less than 1 cm, 1–2.5 cm, 2.5–5 cm, 5–10 cm, and greater than 10 cm. For each distance tested, the valves were exposed 100 times to the tablet with the cover, resulting in 500 total valve exposures. The tablet alone, without the cover, was also tested at distances of less than 1 cm for 30 valve exposures. Changes in valve performance-level settings were recorded. Results The maximum recorded magnetic flux density of a tablet with a cover was 17.0 mT, and the maximum recorded magnetic flux density of the tablet alone was 7.6 mT. In 100 exposures at distances between 0 and 1 cm, 58% of valves had different settings following exposure. At distances greater than 1 cm but less than 2.5 cm, 5% of valves in 100 exposures had setting changes. Only a single setting change was noted in 100 exposures at distances greater than 2.5 cm but less than 5 cm. No setting changes were noted at distances greater than 5 cm, including 100 exposures between 5 and 10 cm, and 100 exposures of more than 10 cm. For the 30 valve exposures to the tablet without a cover, 20 valve performance-level changes (67%) were noted. Conclusions Based on these results, exposure to tablet devices may alter programmable shunt valve settings.





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Functional brain activity and presynaptic dopamine uptake in patients with Parkinson's disease and m

Publication year: 2012
Source:The Lancet Neurology
Urban Ekman, Johan Eriksson, Lars Forsgren, Susanna Jakobson Mo, Katrine Riklund, Lars Nyberg
Background Many patients with Parkinson's disease have mild cognitive impairment (MCI). Deficits in executive functions and working memory suggest dysfunctional frontostriatal brain circuitry. We aimed to assess brain responses during a working memory task in a cohort of newly diagnosed drug-naive patients with Parkinson's disease with and without MCI. Methods Participants were recruited within a prospective cohort study of incident patients with idiopathic parkinsonism, including Parkinson's disease. Between Jan 1, 2004, and April 30, 2009, all physicians in the Umeå catchment area were requested to refer all individuals with suspected parkinsonism to the Department of Neurology at Umeå University. Included patients fulfilled the UK Parkinson's Disease Society Brain Bank clinical diagnostic criteria for Parkinson's disease. Control individuals were matched on the basis of age and sex with the first 50 patients included in the study. Participants who scored 1·5 SDs or more below the population mean on at least two cognitive measures were diagnosed with MCI. The primary outcome measures were functional MRI blood-oxygen-level-dependent signal and SPECT presynaptic uptake. Functional MRI was done during a verbal two-back working memory task. Presynaptic dopamine SPECT was done to assess presynaptic striatal dopaminergic system integrity. Event-related transient analyses of functional MRI data were done for the whole brain and for frontostriatal regions of interest, and semi-quantitative SPECT analyses were done for striatal regions of interest. Findings Compared with controls (n=24), patients with Parkinson's disease (n=77) had under-recruitment in an extensive brain network including bilateral striatal and frontal regions (p<0·001). Within the Parkinson's disease group, patients with Parkinson's disease and MCI (n=30) had additional under-recruitment in the right dorsal caudate nucleus (p=0·005) and the bilateral anterior cingulate cortex (p<0·001) compared with patients with Parkinson's disease without MCI (n=26). In patients with Parkinson's disease and MCI, SPECT uptake in the right caudate was lower than in patients with Parkinson's disease without MCI (p=0·008) and correlated with striatal functional MRI blood-oxygen-level-dependent signal (r=0·32, p=0·031). Interpretation These altered brain responses in patients with Parkinson's disease and MCI suggest that cognitive impairment is linked to frontostriatal dysfunction. Funding Swedish Medical Research Council, Swedish Parkinson Foundation, Swedish Parkinson's Disease Association, Umeå University, Kempe Foundation, Foundation for Clinical Neuroscience at Umeå University Hospital, Västerbotten County Council (ALF), King Gustaf V's and Queen Victoria's Freemason Foundation, Knut and Alice Wallenberg Foundation, and Swedish Brain Power.






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Good medicine rather than new medicines

Truly new medicines are in short supply these days. A wonder drug in any field would be—well—wonderful, but such things are increasingly rare (BMJ 2010;340:c2115). Drug development and research are...





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Saturday, June 23, 2012

Seizure-free and neuropsychological outcomes after temporal lobectomy with amygdalohippocampectomy i

Journal of Neurosurgery: Pediatrics, Volume 0, Issue 0, Page 1-5, Ahead of Print.
Object Temporal lobe epilepsy is an uncommon clinical syndrome in the pediatric population. The most common underlying pathologies include low-grade gliomas, cortical dysplasia, and, less commonly, hippocampal sclerosis (HS). There is a paucity of data on neuropsychological and seizure-free outcomes in these patients after temporal lobectomy. In this study, the authors reviewed their seizure-free and neuropsychological outcomes after temporal lobectomy for pediatric HS. Methods The authors retrospectively reviewed the medical records of pediatric patients with HS who underwent anterior temporal lobectomy and amygdalohippocampectomy between 1998 and 2011 at the Cleveland Clinic. Results of neuropsychological assessment before and after surgery and seizure-free outcome at last follow-up were obtained. Results Forty-five patients met the inclusion criteria. Thirty-four (76%) patients had pathology of HS alone and 10 (22%) had HS and cortical dysplasia. The mean duration of follow-up was 60.2 months. Eighty-four percent of patients had postoperative Engel Class I or II outcomes. Neuropsychological outcomes remained unchanged or minimally improved postoperatively. Conclusions Seizure-free outcomes in pediatric HS are similar to historical rates in adult HS. Neuropsychological assessments remain stable after temporal lobectomy. Standard temporal lobectomy should be considered in pediatric patients with medically intractable epilepsy secondary to HS.





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Consensus definitions of complications for accurate recording and comparisons of surgical outcomes i

Journal of Neurosurgery: Pediatrics, Volume 0, Issue 0, Page 1-7, Ahead of Print.
Object Monitoring and recording of complications in pediatric neurosurgery are important for quality assurance and in particular for improving outcomes. Lack of accurate or mutually agreed upon definitions hampers this process and makes comparisons between centers, which is an important method to improve outcomes, difficult. Therefore, the Canadian Pediatric Neurosurgery Study Group created definitions of complications in pediatric neurosurgery with consensus among 13 Canadian pediatric neurosurgical centers. Methods Definitions of complications were extracted from randomized trials, prospective data collection studies, and the medical literature. The definitions were presented at an annual meeting and were subsequently recirculated for anonymous comment and revision, assembled by a third party, and re-presented to the group for consensus. Results Widely used definitions of shunt failure were extracted from previous randomized trials and prospective studies. Definitions for wound infections were extracted from the definitions from the Centers for Disease Control and Prevention. Postoperative neurological deficits were based on the Pediatric Stroke Outcome Measure. Other definitions were created and modified by consensus. These definitions are now currently in use across the Canadian Pediatric Neurosurgery Study Group centers in Morbidity and Mortality data collection and for subsequent comparison studies. Conclusions Coming up with consensus definitions of complications in pediatric neurosurgery is a first step in improving the quality of outcomes. It is a dynamic process, and further refinements are anticipated. Center to center comparison will hopefully allow significant variations in outcomes to be identified and acted upon.





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Complex Chiari malformations in children: an analysis of preoperative risk factors for occipitocervi

Journal of Neurosurgery: Pediatrics, Volume 0, Issue 0, Page 1-8, Ahead of Print.
Object Chiari malformation Type I (CM-I) is a congenital anomaly often treated by decompressive surgery. Patients who fail to respond to standard surgical management often have complex anomalies of the craniovertebral junction and brainstem compression, requiring reduction and occipitocervical fusion. The authors hypothesized that a subgroup of "complex" patients defined by specific radiographic risk factors may have a higher rate of requiring occipitocervical fusion. Methods A retrospective review was conducted of clinical and radiographic data in pediatric patients undergoing surgery for CM-I between 1995 and 2010. The following radiographic criteria were identified: scoliosis, syringomyelia, CM Type 1.5, medullary kinking, basilar invagination, tonsillar descent, craniocervical angulation (clivoaxial angle [CXA] < 125°), and ventral brainstem compression (pB–C2 ≥ 9 mm). A multivariate Cox regression analysis was used to determine the independent association between occipitocervical fusion and each variable. Results Of the 206 patients who underwent CM decompression with or without occipitocervical fusion during the study period, 101 had preoperative imaging available for review and formed the study population. Mean age at surgery was 9.1 years, and mean follow-up was 2.3 years. Eighty-two patients underwent suboccipital decompression alone (mean age 8.7 years). Nineteen patients underwent occipitocervical fusion (mean age 11.1 years), either as part of the initial surgical procedure or in a delayed fashion. Factors demonstrating a significantly increased risk of requiring fusion were basilar invagination (HR 9.8, 95% CI 2.2–44.2), CM 1.5 (HR 14.7, 95% CI 1.8–122.5), and CXA < 125° (HR 3.9, 95% CI 1.2–12.6). Conclusions Patients presenting with basilar invagination, CM 1.5, and CXA < 125° are at increased risk of requiring an occipitocervical fusion procedure either as an adjunct to initial surgical decompression or in a delayed fashion. Patients and their families should be counseled in regard to these findings as part of a preoperative CM evaluation.





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Comparative effectiveness review of treatment options for pituitary microadenomas in acromegaly

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-17, Ahead of Print.
Object Acromegaly, a syndrome of excess growth hormone (GH) secretion typically caused by a GH-secreting pituitary adenoma, reduces life expectancy by approximately 10 years when left untreated. Treatment of acromegaly involves combinations of one or more discrete therapeutic modalities to achieve biochemical control. Unfortunately, data capable of informing decisions among alternate management strategies are presently lacking. Methods The authors performed a comparative effectiveness research (CER) review integrating efficacy, cost, and quality of life (QOL) analysis for treatment strategies comprising various combinations of surgery, radiotherapy, stereotactic radiosurgery, and pharmacotherapy in patients with acromegaly caused by a pituitary microadenoma. A management decision tree was used to identify 5 treatment strategies, each with up to 4 potential treatment steps. Efficacy was assessed using recent literature reports of biochemical control rates for each modality. Cost estimations were derived from wholesale drug prices and from the Healthcare Cost and Utility Project. Quality of life data were obtained from studies utilizing the Acromegaly Quality of Life Questionnaire. Results Individual treatment modalities were analyzed and ranked in each of 3 domains: highest rate of success, lowest cost, and highest QOL, and these scores were combined to facilitate comparison of overall effectiveness of each of the management strategies. These aggregate effectiveness scores were used to compare the 5 strategies from the decision tree, and a novel strategy was also proposed. Conclusions The choice of management strategy must be individualized for each patient with acromegaly. This CER analysis provides a comprehensive framework to inform clinical decisions among alternate management strategies in patients with GH-secreting pituitary microadenomas.





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Intracranial hypotension producing reversible coma: a systematic review, including three new cases

Journal of Neurosurgery, Volume 0, Issue 0, Page 1-14, Ahead of Print.
Intracranial hypotension is a disorder of CSF hypovolemia due to iatrogenic or spontaneous spinal CSF leakage. Rarely, positional headaches may progress to coma, with frequent misdiagnosis. The authors review reported cases of verified intracranial hypotension–associated coma, including 3 previously unpublished cases, totaling 29. Most patients presented with headache prior to neurological deterioration, with positional symptoms elicited in almost half. Eight patients had recently undergone a spinal procedure such as lumbar drainage. Diagnostic workup almost always began with a head CT scan. Subdural collections were present in 86%; however, intracranial hypotension was frequently unrecognized as the underlying cause. Twelve patients underwent one or more procedures to evacuate the collections, sometimes with transiently improved mental status. However, no patient experienced lasting neurological improvement after subdural fluid evacuation alone, and some deteriorated further. Intracranial hypotension was diagnosed in most patients via MRI studies, which were often obtained due to failure to improve after subdural hematoma (SDH) evacuation. Once the diagnosis of intracranial hypotension was made, placement of epidural blood patches was curative in 85% of patients. Twenty-seven patients (93%) experienced favorable outcomes after diagnosis and treatment; 1 patient died, and 1 patient had a morbid outcome secondary to duret hemorrhages. The literature review revealed that numerous additional patients with clinical histories consistent with intracranial hypotension but no radiological confirmation developed SDH following a spinal procedure. Several such patients experienced poor outcomes, and there were multiple deaths. To facilitate recognition of this treatable but potentially life-threatening condition, the authors propose criteria that should prompt intracranial hypotension workup in the comatose patient and present a stepwise management algorithm to guide the appropriate diagnosis and treatment of these patients.





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Impact of an intensive care unit diary on psychological distress in patients and relatives*

Objective: To assess the impact of an intensive care unit diary on the psychological well-being of patients and relatives 3 and 12 months after intensive care unit discharge. Design: Prospective single-center study with an intervention period between two control periods. Setting: Medical-surgical intensive care unit in a 460-bed tertiary hospital. Patients: Consecutive patients from May 2008 to November 2009 and their relatives. Study inclusion occurred after the fourth day in the intensive care unit. Interventions: A diary written by both the patient's relatives and the intensive care unit staff. Measurements and Main Results: Patients and relatives completed the Hospital Anxiety and Depression Scale and Peritraumatic Dissociative Experiences Questionnaire 3 months after intensive care unit discharge, and completed the Impact of Events Scale assessing posttraumatic stress–related symptoms 12 months after intensive care unit discharge. Of the 378 patients admitted during the study period, 143 were included (48 in the prediary period, 49 in the diary period, and 46 in the postdiary period). In relatives, severe posttraumatic stress–related symptoms after 12 months varied significantly across periods (prediary 80%, diary 31.7%, postdiary 67.6%; p<.0001). Similar results were obtained in the posttraumatic stress–related symptom score after 12 months in the surviving patients (prediary 34.6 ± 15.9, diary 21 ± 12.2, and postdiary 29.8 ± 15.9; p = .02). Conclusions: The intensive care unit diary significantly affected posttraumatic stress–related symptoms in relatives and surviving patients 12 months after intensive care unit discharge.





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Tuberculoma of the brain with unknown primary infection in an immunocompetent host

Publication year: 2012
Source:Journal of Clinical Neuroscience
Karthik Madhavan, Gabriel Widi, Ashish Shah, Carol Petito, Bruno V. Gallo, Ricardo J. Komotar
Isolated cerebral tubercular abscess is uncommon in immunocompetent hosts. Our patient had a tuberculoma with no known primary and an atypical MRI appearance. We present a 67-year-old African–American male with complex partial seizures. A CT scan of the brain revealed a new right frontal mass which was not found on imaging two years prior. In view of the patient's age and absence of any known primary malignancy, a primary brain tumor was considered to be the likely diagnosis. On MRI, the mass did not display ring enhancement or necrosis. Rather, the mass was lobulated, with near-uniform enhancement of the lesion with a surrounding high fluid-attenuated inversion recovery signal predominantly in the right frontal region, which extended inferiorly to the parietal region. The lesion showed a few punctate foci of low signal intensity on gradient echo MRI sequences, suggestive of hemorrhage. The mode of infection is unknown. However, it is important to include tuberculosis as a differential diagnosis, especially if the lesion appears to be non-primary, if a primary neoplasm or other metastases are not identified on further investigation, and in a patient of African–American ethnicity. To our knowledge, this is the first record of an isolated tubercular abscess of the brain in a developed country.






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Friday, June 22, 2012

DBS Target Affects Cognition in Parkinson's

Improvements remain stable for up to 3 years and don't differ significantly whether the target is the subthalamic nucleus or globus pallidus interna, although there may be benefits with the latter.
Medscape Medical News





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Risk Factors for Intracranial Infection Secondary to Penetrating Craniocerebral Gunshot Wounds in Ci

Publication year: 2012
Source:World Neurosurgery
Carlos Mario Jimenez, Jonathan Polo, Julian Andres España
Objective To determine risk factors for intracranial infection secondary to penetrating craniocerebral gunshot wounds (PCGW) in civilian practice, in patients who underwent surgery with removal of bullet fragments, wound debridement and watertight dural closure. Methods An observational, analytical, prospective, cohort-type study was conducted with follow-up to a group of patients with PCGW caused by low velocity projectile admitted between January 2000 and November 2010. Patients were included in a 160-patient study, 59 of whom were administered prophylactic antibiotics based on the treating neurosurgeon's decision. Average follow-up time was 39 months (range: 3 – 92 months). Results 40 patients (25%) showed infection; 20 patients received antibiotics (20/59, 33.9%), and 20 patients did not receive antibiotics (20/101, 19.8%). Three variables were independent risk factors for infection: Persistence of parenchymal osseous or metallic fragments after surgery (p<0.0001. RR: 7.45), projective trajectory through a natural cavity with contaminating flora (p: 0.03, RR: 2.84), and prolonged hospitalization time (p<0.0001, RR: 3.695). Conclusion Administration of prophylactic antibiotics was not associated to the incidence of intracranial infection secondary to PCGW. Projectile trajectory through potentially contaminating cavities, persistence of intra-parenchymal osseous or metallic fragments after surgery and prolonged hospital stay were independent risk factors for such an infection.






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DBS for the Treatment of Alzheimer's Disease and Dementias

Publication year: 2012
Source:World Neurosurgery
Adrian W. Laxton, Andres M. Lozano
Objective To review the use of deep brain stimulation (DBS) for the treatment of dementia. Methods A Pubmed literature search was conducted to identify all studies that have investigated the use of DBS for the treatment of dementia. Results Three studies have examined the use of DBS for dementia. One study involved fornix DBS for Alzheimer's disease (AD), and two studies involved DBS of the nucleus basalis of Meynert (NBM), one to treat AD and the other for Parkinson's disease dementia (PDD). Conclusion Evidence for the use of DBS to treat dementia is preliminary and limited. Fornix and NBM DBS can influence activity in the pathological neural circuits that underlie AD and PDD. Further investigation into the potential clinical effects of DBS for dementia is warranted.






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Chronic Subdural Hematoma: A Sentinel Health Event

Publication year: 2012
Source:World Neurosurgery
Travis M. Dumont, Anand I. Rughani, Tara Goeckes, Bruce I. Tranmer
Objective Elderly patients are prone towards developing chronic subdural hematomas due to incidence of co-morbidities requiring anti-platelet or anticoagulant medications and a predilection for falls. The authors propose that chronic subdural hematoma (CSDH) should be conceived as a sentinel event in the elderly and offer an analysis of the long-term survival following diagnosis. Methods A retrospective review of 301 consecutive patients aged 55 years or older admitted to an academic medical center with primary diagnosis of CSDH between January 1996 and January 2010 was performed. The effects of advanced age and surgical intervention on survival were independently assessed. These groups were compared to standardized mortality ratios on the basis of patient age at time of presentation. Results Mortality incidence after diagnosis of CSDH increases with increased age at presentation. For all patients, the median survival was roughly four years after diagnosis (4.0 ± 0.5 years). Median survival is decreased with older age at presentation, to a nadir of 1.5 ± 0.6 years for patients aged over 85 years (p = 0.0003, log-rank test). Compared to the reference data from the Centers of Disease Control, the one year standardized mortality ratio was increased in all age groups. An asymmetric increase in standardized mortality ratio was seen between age groups, with the greatest effect on the youngest subpopulation (standardized mortality ratio 2.9). Conclusions The increased mortality rates in patients with chronic subdural hematomas relative to standardized mortality data corroborate the conception of subdural hematoma as sentinel health event.






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Dabigatran: A Primer For Neurosurgeons

Publication year: 2012
Source:World Neurosurgery
Jennifer E. Fugate, Alejandro A. Rabinstein, Robert D. McBane, Giuseppe Lanzino
Objective To present an overview of dabigatran, a new anticoagulant, and discuss the implications for the perioperative management of patients taking dabigatran. Methods We reviewed the English literature pertaining to the new oral anticoagulant, dabigatran (Pradaxa). Results Dabigatran has the advantage of providing rapid and steady anticoagulation without requiring laboratory monitoring. However, the fact that no practical, reliable method of monitoring of the anticoagulant effects is available constitutes a challenge when contemplating urgent neurosurgical procedures in patients treated with this medication. Although the risk of intracranial hemorrhage with dabigatran was lower than with warfarin in the large trial leading to the approval of the drug, the management of these complications may be problematic because there is no current antidote. Conclusion We present a basic overview of dabigatran, discuss the implications for the perioperative management of patients taking this new anticoagulant, and offer recommendations for the management of intracranial hemorrhage related to this drug.






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Rebleeding after aneurysmal subarachnoid hemorrhage: a literature review

Publication year: 2012
Source:World Neurosurgery
Carl Christian Larsen, Jens Astrup
Objective Rebleeding is a major contributor to morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). However, little is known to what causes rebleeding. During the last decades several risk factors have been identified to be associated with rebleeding although several discrepancies exist. The aim of this review is to summarize the current knowledge of the mechanisms leading to rebleeding and the prevention hereof after SAH. Methods A literature search was performed to investigate factors associated with rebleeding after SAH. Results The review of the literature revealed that rebleeding is a complex and multifactorial event involving haemostasis, pathophysiological and anatomical factors. Administration of antifibrinolytics has been shown to have a dramatic effect on the rebleeding rate so changes in coagulation and fibrinolysis must be involved in rebleeding. Conclusion Further studies are warranted before the exact mechanisms leading to rebleeding is established and the optimal preventive measures are made available. Currently antifibrinolytic therapy remains the only realistic protective measure during the initial 6 hours after SAH during which the rebleeding rate is highest.






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Prevalence and Risk Factors of Epilepsy Among School Children in Eastern Turkey

Abstract: Epilepsy is a serious chronic brain disorder of childhood. We performed a cross-sectional prevalence study, determined the prevalence of childhood epilepsy, and identified the significance of certain risk factors for epilepsy among 1625 primary-school students aged 6-14 years, living in the center of Kars province. A questionnaire was prepared according to the definitions and principles of the Commission on Epidemiology and Prognosis, International League Against Epilepsy. Twenty-two children were diagnosed as epileptic. The point prevalence of active epilepsy in males was 4.9/1000, and in females 12.4/1000, representing a total of 8.6/1000. The cumulative prevalence in males was 11.0/1000, and 16.1/1000 in females, representing a total of 13.5/1000. Febrile convulsions, family history of epilepsy, serious maternal illness during pregnancy, a history of head trauma, antenatal/postnatal problems, and a history of neonatal jaundice were statistically significantly related to the development of epilepsy.





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Researchers Help Develop First Brain Map Of Love And Desire

Thanks to modern science, we know that love lives in the brain, not in the heart. But where in the brain is it - and is it in the same place as sexual desire? A recent international study is the first to draw an exact map of these intimately linked feelings...





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Mulheres na Ciência

Esta semana estive em um evento na Academia Brasileira de Ciências e fiquei muito feliz ao ouvir o presidente (Jacob Palis) dizer que a 12,5% dos afiliados da ABC são mulheres. Mais ainda, essa proporção é superior às Academias de Ciências do Reino Unido e da França, segundo o professor Palis. Como colocado no evento, não é muito mas é um bom começo. Como já falado anteriormente aqui e em outras





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Thursday, June 21, 2012

Effects of Mobile and Digital Support for a Structured, Competency-Based Curriculum in Neurosurgery

BACKGROUND: Changes in neurosurgical practice and graduate medical education impose new challenges for training programs. OBJECTIVE: We present our experience providing neurosurgical residents with digital and mobile educational resources in support of the departmental academic activities. METHODS: A weekly mandatory conference program for all clinical residents based on the Accreditation Council for Graduate Medical Education competencies, held in protected time, was introduced. Topics were taught through didactic sessions and case discussions. Faculty and residents prepare high-quality presentations, equivalent to peer-review leading papers or case reports. Presentations are videorecorded, stored in a digital library, and broadcasted through our Website and iTunes U. Residents received mobile tablet devices with remote access to the digital library, applications for document/video management, and interactive teaching tools. RESULTS: Residents responded to an anonymous survey, and performances on the Self-Assessment in Neurological Surgery examination before and after the intervention were compared. Ninety-two percent reported increased time used to study outside the hospital and attributed the habit change to the introduction of mobile devices; 67% used the electronic tablets as the primary tool to access the digital library, followed by 17% hospital computers, 8% home computers, and 8% personal laptops. Forty-two percent have submitted operative videos, cases, and documents to the library. One year after introducing the program, results of the Congress of Neurological Surgeons–Self-Assessment in Neurological Surgery examination showed a statistically significant improvement in global scoring and improvement in 16 of the 18 individual areas evaluated, 6 of which reached statistical significance. CONCLUSION: A structured, competency-based neurosurgical education program supported with digital and mobile resources improved reading habits among residents and performance on the Congress of Neurological Surgeons–Self-Assessment in Neurological Surgery examination. ABBREVIATIONS: ACGME, Accreditation Council for Graduate Medical Education CNS, Congress of Neurological Surgeons SANS, Self-Assessment in Neurological Surgery





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Structural plasticity upon learning: regulation and functions

Structural plasticity upon learning: regulation and functions

Nature Reviews Neuroscience 13, 478 (2012). doi:10.1038/nrn3258

Authors: Pico Caroni, Flavio Donato & Dominique Muller

Recent studies have provided long-sought evidence that behavioural learning involves specific synapse gain and elimination processes, which lead to memory traces that influence behaviour. The connectivity rearrangements are preceded by enhanced synapse turnover, which can be modulated through changes in inhibitory connectivity. Behaviourally related synapse






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Results of Kids' Brain Injury Hard to Predict (CME/CE)

(MedPage Today) -- Outcomes after brain injury in children remain difficult to predict and the evidence base is limited, posing challenges for families and clinicians about treatment decisions, a literature review concluded.





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Assessing the Evolution of Publications by Brazilian Spine Surgeons in the Last Decade

Publication year: 2012
Source:World Neurosurgery
Asdrubal Falavigna, Ricardo Vieira Botelho, Helton Luiz Aparecido Defino, Alisson Roberto Teles, Pedro Guarise da Silva







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Tuesday, June 19, 2012

Brainstem hemorrhage following decompressive craniectomy

Publication year: 2012
Source:Journal of Clinical Neuroscience
Laurent Lonjaret, Maxime Ros, Sergio Boetto, Olivier Fourcade, Thomas Geeraerts
Decompressive craniectomy (DC) is used for the management of refractory raised intracranial pressure, but the impact of DC on surgical outcome is still controversial. We report a 21-year-old man admitted to our hospital after a road traffic accident. The brain CT scan revealed a left hemispheric acute subdural hematoma. After DC, he developed a brainstem hemorrhage. Recovery was, however, good.






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Monday, June 18, 2012

Confira Neuroexame

Neuroexame

Confira este app na App Store:

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Neuroexame

MedPhone.com.br

Categoria: Medicina

Atualizado: 08/05/2012
28 avaliações



iTunes Para Mac e Windows
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Confira Traumatismo Crânio-Encefálico (TCE)

Traumatismo Crânio-Encefálico (TCE)

Confira este app na App Store:

Cover Art

Traumatismo Crânio-Encefálico (TCE)

Fuze.cc

Categoria: Medicina

Atualizado: 07/06/2012
8 avaliações



iTunes Para Mac e Windows
Observe que você não foi adicionado a nenhuma lista de e-mail.
Direitos autorais © 2012 Apple Inc. Todos os direitos reservados

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