Endovascular Treatment of Intracranial Aneurysms: Long-Term Follow-up

Endovascular treatment of intracranial aneurysms is increasingly used and has evolved as an alternative to surgical clipping. However, its long-term efficacy has yet to be established. This retrospective hospital based (tertiary teaching hospital) study aimed to identify factors that might be important in predicting initial efficacy of this treatment and a long-term follow-up to study the clinical and angiographic results of treated aneurysms. A total of 80 aneurysms in 78 patients were treated and analyzed, and the percentage of occlusion calculated. Overall, 51/80 (64 %) cases were treated with selective endovascular coil occlusion and 29/80 (36 %) by parent artery occlusion. The shape of the aneurysm rest was noted on the immediate post treatment and follow-up angiograms. Immediate and follow-up clinical status was also noted using the Glasgow outcome scale. The clinical and radiological changes on follow-up were assessed and possible factors involved were analyzed. Of the 50 patients of intracranial aneurysms that underwent selective aneurysm coiling, good immediate outcome (Glasgow outcome scale 1 and 2) was seen in 36/50 (72 %) cases. Narrow necked aneurysms showed a good immediate result (90–100 % packing) in all cases 28/28 (100 %). Amongst the wide necked aneurysms, good packing (90–100 %) was achieved in 17/23 (73 %) cases. Amongst the cases treated with parent artery occlusion, complete occlusion was noted in 20/29 (69 %) cases. No subarachnoid hemorrhage was seen in any of the followed up cases of coiled aneurysms. A statistically significant relationship was noted between aneurysm neck size and immediate angiographic outcome. Long-term angiographic recurrences were found more often in large aneurysms. Endovascular treatment of intracranial aneurysms is a safe and effective treatment modality that offers protection from recurrent subarachnoid hemorrhage.

From Dyadic Ties to Information Infrastructures: Care-Coordination between Patients, Providers, Students and Researchers. Contribution of the Health Informatics Education Working Group

OBJECTIVE

To share how an effectual merging of local and online networks in low resource regions can supplement and strengthen the local practice of patient centered care through the use of an online digital infrastructure powered by all stakeholders in healthcare. User Driven Health Care offers the dynamic integration of patient values and evidence based solutions for improved medical communication in medical care.

INTRODUCTION

This paper conceptualizes patient care-coordination through the lens of engaged stakeholders using digital infrastructures tools to integrate information technology. We distinguish this lens from the prevalent conceptualization of dyadic ties between clinician-patient, patient-nurse, clinician-nurse, and offer the holistic integration of all stakeholder inputs, in the clinic and augmented by online communication in a multi-national setting.

METHODS

We analyze an instance of the user-driven health care (UDHC), a network of providers, patients, students and researchers working together to help manage patient care. The network currently focuses on patients from LMICs, but the provider network is global in reach. We describe UDHC and its opportunities and challenges in care-coordination to reduce costs, bring equity, and improve care quality and share evidence.

CONCLUSION

UDHC has resulted in coordinated global based local care, affecting multiple facets of medical practice. Shared information resources between providers with disparate knowledge, results in better understanding by patients, unique and challenging cases for students, innovative community based research and discovery learning for all.

The role of bile acids in reducing the metabolic complications of obesity after bariatric surgery: a systematic review

BACKGROUND

Bariatric surgery is currently the most efficacious treatment for obesity and its associated metabolic co-morbidities, such as diabetes. The metabolic improvements occur through both weight-dependent and weight-independent mechanisms. Bile acids (BAs) have emerged as key signalling molecules that have a central role in modulating many of the physiological effects seen after bariatric surgery. This systematic review assesses the evidence from both human and animal studies for the role of BAs in reducing the metabolic complications of obesity following bariatric surgery.

METHODS

We conducted a systematic search of Medline and Embase databases to identify all articles investigating the role of BAs in mediating the metabolic changes observed following bariatric surgery in both animal and human studies. Boolean logic was used with relevant search terms, including the following MeSH terms: 'bile acids and salts', 'bariatric surgery', 'metabolic surgery', 'gastrointestinal tract/surgery' and 'obesity/surgery'.

RESULTS

Following database searches (n=1197), inclusion from bibliography searches (n=2) and de-duplication (n=197), 1002 search results were returned. Of these, 132 articles were selected for full-text review, of which 38 articles were deemed relevant and included in the review. The findings support the effects of BAs on satiety, lipid and cholesterol metabolism, incretins and glucose homoeostasis, energy metabolism, gut microbiota and endoplasmic reticulum stress following bariatric surgery. Many of these metabolic effects are modulated through the BA receptors FXR and TGR5. We also explore a possible link between BAs and carcinogenesis following bariatric surgery.

CONCLUSIONS

Overall there is good evidence to support the role of BAs in the metabolic effects of bariatric surgery through the above mechanisms. BAs could serve as a novel therapeutic pharmacological target for the treatment of obesity and its associated co-morbidities.

Impaired cerebral autoregulation is associated with vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Cerebral autoregulation may be impaired in the early days after subarachnoid hemorrhage (SAH). The purpose of this study was to examine the relationship between cerebral autoregulation and angiographic vasospasm (aVSP) and radiographic delayed cerebral ischemia (DCI) in patients with SAH.

METHODS

Sixty-eight patients (54±13 years) with a diagnosis of nontraumatic SAH were studied. Dynamic cerebral autoregulation was assessed using transfer function analysis (phase and gain) of the spontaneous blood pressure and blood flow velocity oscillations on days 2 to 4 post-SAH. aVSP was diagnosed using a 4-vessel conventional angiogram. DCI was diagnosed from CT. Decision tree models were used to identify optimal cut-off points for clinical and physiological predictors of aVSP and DCI. Multivariate logistic regression models were used to develop and validate a risk scoring tool for each outcome.

RESULTS

Sixty-two percent of patients developed aVSP, and 19% developed DCI. Patients with aVSP had higher transfer function gain (1.06±0.33 versus 0.89±0.30; P=0.04) and patients with DCI had lower transfer function phase (17.5±39.6 versus 38.3±18.2; P=0.03) compared with those who did not develop either. Multivariable scoring tools using transfer function gain>0.98 and phase<12.5 were strongly predictive of aVSP (92% positive predictive value; 77% negative predictive value; area under the receiver operating characteristic curve, 0.92) and DCI (80% positive predictive value; 91% negative predictive value; area under the curve, 0.94), respectively.

CONCLUSIONS

Dynamic cerebral autoregulation is impaired in the early days after SAH. Including autoregulation as part of the initial clinical and radiographic assessment may enhance our ability to identify patients at a high risk for developing secondary complications after SAH.

Transcranial Doppler ultrasound: technique and application

Transcranial Doppler (TCD) ultrasound provides rapid, noninvasive, real-time measures of cerebrovascular function. TCD can be used to measure flow velocity in the basal arteries of the brain to assess relative changes in flow, diagnose focal vascular stenosis, or to detect embolic signals within these arteries. TCD can also be used to assess the physiologic health of a particular vascular territory by measuring blood flow responses to changes in blood pressure (cerebral autoregulation), changes in end-tidal CO2 (cerebral vasoreactivity), or cognitive and motor activation (neurovascular coupling or functional hyperemia). TCD has established utility in the clinical diagnosis of a number of cerebrovascular disorders such as acute ischemic stroke, vasospasm, subarachnoid hemorrhage, sickle cell disease, as well as other conditions such as brain death. Clinical indication and research applications for this mode of imaging continue to expand. In this review, the authors summarize the basic principles and clinical utility of TCD and provide an overview of a few TCD research applications.

Optimization of cone beam CT exposure for pre-surgical evaluation of the implant site

OBJECTIVES

The aim of this study was to investigate the possibility of reducing patient X-ray dose in the course of implant site evaluation.

METHODS

Retrospective practice-based study using a Morita F170 Accuitomo cone beam CT (CBCT) scanner with variable exposure parameters and operating a small cylindrical field of view of 4 cm diameter and 4 cm height. 6 experienced dental surgeons scored the image quality of dental scans on a 5-point scale for adequacy in providing the required information in 2 categories: bone height from alveolar crest to the relevant anatomical structure and bone width.

RESULTS

Lower-dose protocols only marginally affected the preference of the reviewers of the resulting images.

CONCLUSIONS

There is potential to reduce patient dose very significantly in CBCT examinations for implant site evaluation.

Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare

Background

The demand for the highest-quality patient care coupled with pressure on funding has led to the increasing use of quality improvement (QI) methodologies from the manufacturing industry. The aim of this systematic review was to identify and evaluate the application and effectiveness of these QI methodologies to the field of surgery.

Methods

MEDLINE, the Cochrane Database, Allied and Complementary Medicine Database, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Embase, Health Business™ Elite, the Health Management Information Consortium and PsycINFO® were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Empirical studies were included that implemented a described QI methodology to surgical care and analysed a named outcome statistically.

Results

Some 34 of 1595 articles identified met the inclusion criteria after consensus from two independent investigators. Nine studies described continuous quality improvement (CQI), five Six Sigma, five total quality management (TQM), five plan-do-study-act (PDSA) or plan-do-check-act (PDCA) cycles, five statistical process control (SPC) or statistical quality control (SQC), four Lean and one Lean Six Sigma; 20 of the studies were undertaken in the USA. The most common aims were to reduce complications or improve outcomes (11), to reduce infection (7), and to reduce theatre delays (7). There was one randomized controlled trial.

Conclusion

QI methodologies from industry can have significant effects on improving surgical care, from reducing infection rates to increasing operating room efficiency. The evidence is generally of suboptimal quality, and rigorous randomized multicentre studies are needed to bring evidence-based management into the same league as evidence-based medicine.

The functional role of the alpha-1 adrenergic receptors in cerebral blood flow regulation

Cerebral vasculature is richly innervated by the α-1 adrenergic receptors similar to that of the peripheral vasculature. However, the functional role of the α-1adrenergic receptors in cerebral blood flow (CBF) regulation is yet to be established. The traditional thinking being that during normotension and normocapnia sympathetic neural activity does not play a significant role in CBF regulation. Reports in the past have stated that catecholamines do not penetrate the blood brain barrier (BBB) and therefore only influence cerebral vessels from outside the BBB and hence, have a limited role in CBF regulation. However, with the advent of dynamic measurement techniques, beat-to-beat CBF assessment can be done during dynamic changes in arterial blood pressure. Several studies in the recent years have reported a functional role of the α-1adrenergic receptors in CBF regulation. This review focuses on the recent developments on the role of the sympathetic nervous system, specifically that of the α-1 adrenergic receptors in CBF regulation.

The role of robotic assisted laparoscopy for oesophagogastric oncological resection; an appraisal of the literature

The introduction of surgical robotics to the field of surgical oncology brings with it an expectation not only of improved vision, instrumentation, and precision but also as a result, a potential for improved oncological outcomes. The current interest in the field of oesophagogastric oncology is explored in this review together with the benefits, real and potential, that robotic assistance offers surgical cancer resection as well as some of the limiting factors which may be hampering its uptake into current surgical practice. A systematic review of all the published literature up until April 2010 was examined across the field of esophageal and gastric cancer resection. A quantitative assessment of the oncological, operative, and functional outcomes was determined from each procedure. The level of evidence behind the results was determined using the Oxford Centre for Evidence-based Medicine Levels of Evidence; Therapy and Prevention. Three hundred and five cases from 19 independent studies were included for review. Nine studies explored the outcomes from robotic-assisted esophagectomy and eight, the robotic-assisted gastrectomy. Two articles included small case series of both procedures. The level of evidence was predominantly based on case series or expert opinion (Level 4 or 5) with only three unmatched or poorly matched comparative trials (Level 4) with no randomized trials evident. Improved operative outcomes and hospital stays were demonstrated with a reduction of 2 days when the robotic-assisted gastrectomy technique was employed compared with the open. No improvement in oncological outcomes could be identified with the use of the robot for either oesophageal or gastric cancer resection; however, in terms of short-term oncological outcomes, these were at least equivalent to the open approach for oesophageal cancer and early stage gastric cancer. Robotic-assisted laparoscopic surgery is a feasible technique to use to perform a safe and oncologically sound resection for oesophageal and early gastric cancer. Operative benefits appear to be encouragingly similar to the laparoscopic approach with some demonstration of improvement over the open technique despite a prolonged operative time. However, the level of evidence is suboptimal and more randomized controlled trials and long-term survival studies within a framework of measured and comparable outcomes is required.

Prognostic significance of circulating tumour cells following surgical resection of colorectal cancers: a systematic review

Background:

The role of adjuvant chemotherapy after resection of colorectal cancers (CRCs) is well understood for patients with stage-I or stage-III disease. Its efficacy for those with stage-II disease remains much less clear. Many investigators have sought to identify prognostic markers that might clarify which patients have the highest risk of recurrence and would, therefore, be most likely to benefit from chemotherapy. This systematic review examines evidence for the use of peripherally sampled, circulating tumour cells (CTCs) as such a prognostic marker.

Methods:

A comprehensive literature search was used to identify studies reporting on the significance of CTCs in the postoperative blood of CRC patients.

Results:

Fourteen studies satisfied the inclusion criteria. Six of the nine studies that took blood samples 24 h or more postoperatively found detection of postoperative CTCs to be an independent predictor of cancer recurrence.

Conclusion:

The presence of CTCs in peripheral blood at least 24 h after resection of CRCs is an independent prognostic marker of recurrence. Further studies are needed to clarify the optimal time point for blood sampling and determine the benefit of chemotherapy in CTC-positive patients with stage-II disease.

Microtechnologies in implant and restorative dentistry: A stroll through a digital dental landscape

This is an explanatory article introducing the combination of various technologies used in implant and restorative dentistry. The aim of the article is to provide an overview of some of the techniques supporting the restorative treatment plan at various stages to provide contemporary, state-of-the-art bridgework based on dental implants. It is a discussion of the way existing technologies used in fields of engineering and medicine are brought together to form a complete process.

"Swimming worms in a bare cistern": a sign for moyamoya disease. A case report

Moyamoya disease is a rare cerebrovascular occlusive disorder most often found among the Japanese. It is angiographically defined as a progressive steno-occlusion of the bilateral internal carotid arteries with characteristic abnormal vascular networks, so-called Moyamoya vessels, at the base of the brain. MRI is the initial investigation of choice and we describe an MRI sign to diagnose Moyamoya disease warranting digital subtraction angiography.

The effects of aerobic fitness and β1-adrenergic receptor blockade on cardiac work during dynamic exercise

The purpose of this investigation was to determine whether cardiovascular adaptations characteristic of long-term endurance exercise compensate more effectively during cardioselective β1-adrenergic receptor blockade-induced reductions in sympathoadrenergic-stimulated contractility. Endurance-trained (ET) athletes ( n = 8) and average-trained (AT; n = 8) subjects performed submaximal cycling exercise at moderate [45% maximum oxygen uptake (V̇o2max)] and heavy (70% V̇o2max) workloads, with and without metoprolol. Cardiac output (Q̇c), heart rate (HR), and systolic blood pressure were recorded at rest and during exercise. Cardiac work was calculated from the triple product of HR, stroke volume, and systolic blood pressure, and myocardial efficiency is represented as cardiac work for a given total body oxygen consumption. Metoprolol reduced Q̇c at 45% V̇o2max ( P = 0.004) and 70% V̇o2max ( P = 0.022) in ET subjects, but did not alter Q̇c in the AT subjects. In ET subjects at 45% V̇o2max, metoprolol-induced reductions in Q̇c were a result of decreases in HR ( P < 0.05) and the absence of a compensatory increase in stroke volume ( P > 0.05). The cardiac work and calculated cardiac efficiency were reduced with metoprolol in ET subjects at both exercise intensities and in the AT subjects during the high-intensity workload ( P < 0.01). The cardiac work and the calculated cardiac efficiency were not affected by metoprolol in the AT subjects during the 45% V̇o2max exercise. Therefore, in AT subjects, β-blockade reduced the amount of pressure generation necessary to produce the same amount of work during moderate-intensity exercise. In patients with heart disease receiving metoprolol, a decrease in the generation of cardiac pressure necessary to perform a given amount of work during mild-to-moderate exercise would prove to be beneficial.

Laparoscopic approach to incarcerated and strangulated inguinal hernias

INTRODUCTION

Acute inguinal hernias are a common presentation as surgical emergencies, which have been routinely managed with open surgery. In recent years, the laparoscopic approach has been described by several authors but has been controversial amongst surgeons. We describe the laparoscopic approach to incarcerated/strangulated inguinal hernias based on a review of the literature with regards to its feasibility in laparoscopically managing the acute hernia presentation.

METHODS

A systematic literature search was carried out including Medline with PubMed as the search engine, and Ovid, Embase, Cochrane Collaboration, and Google Scholar databases to identify articles reporting on laparoscopic treatment, reduction, and repair of incarcerated or strangulated inguinal hernias from 1989 to 2008.

RESULTS

Forty-three articles were found, and 7 were included according to the inclusion criteria set. Articles reporting on the use of laparoscopy for the evaluation of the hernia but not reducing and repairing it, the use of the open technique, elective hernia repairs, pediatric series, review articles, and other kinds of hernias were excluded after title and abstract review. This resulted in 16 articles that were reviewed in full. Of these 16 articles, 7 reported on the use of the laparoscopic approach exclusively. From these 7 studies, there were 328 cases reported, 6 conversions, average operating time of 61.3 minutes (SD+/-12.3), average hospital stay of 3.8 days (SD+/-1.2), 34 complications (25 of which were reported as minor), and 17 bowel resections performed either laparoscopically or through a minilaparotomy incision guided laparoscopically.

CONCLUSION

The laparoscopic repair is a feasible procedure with acceptable results; however, its efficacy needs to be studied further, ideally with larger multicenter randomized controlled trials.