Discordance Between Perceptions and Experience of Lumbar Puncture: A Prospective Study

The path to leptomeningeal metastasis

The leptomeninges, the cerebrospinal-fluid-filled tissues surrounding the central nervous system, play host to various pathologies including infection, neuroinflammation and malignancy. Spread of systemic cancer into this space, termed leptomeningeal metastasis, occurs in 5-10% of patients with solid tumours and portends a bleak clinical prognosis. Previous, predominantly descriptive, clinical studies have provided few insights. Recent development of preclinical leptomeningeal metastasis models, alongside genomic, transcriptomic and proteomic sequencing efforts, has provided groundwork for mechanistic understanding and identification of long-needed therapeutic targets. Although previously understood as an anatomically isolated compartment, the leptomeninges are increasingly appreciated as a major conduit of communication between the systemic circulation and the central nervous system. Despite the unique nature of the leptomeningeal microenvironment, the general principles of metastasis hold true: cells metastasizing to the leptomeninges must gain access to the new environment, survive within the space and evade the immune system. The study of leptomeningeal metastasis has the potential to uncover novel site-specific metastatic principles and illuminate the physiology of the leptomeningeal space. In this Review, we provide a biology-focused overview of how metastatic cells reach the leptomeninges, thrive in this nutritionally sparse environment and evade the detection of the omnipresent immune system.

Preferences of Patients with Amyotrophic Lateral Sclerosis for Intrathecal Drug Delivery: Choosing between an Implanted Drug-Delivery Device and Therapeutic Lumbar Puncture

BACKGROUND

Novel intrathecal treatments for amyotrophic lateral sclerosis (ALS) may require delivery using lumbar puncture (LP). Implanted drug-delivery devices (IDDDs) could be an alternative but little is known about patients' preferences for intrathecal drug-delivery methods.

OBJECTIVE

We aimed to elicit preferences of patients with ALS for routine LP and IDDD use.

METHODS

A discrete choice experiment (DCE) and a threshold technique (TT) exercise were conducted online among patients with ALS in the US and Europe. In the DCE, patients made trade-offs between administration attributes. Attributes were identified from qualitative interviews. The TT elicited maximum acceptable risks (MARs) of complications from device implantation surgery. DCE data were analyzed using mixed logit to quantify relative attribute importance (RAI) as the maximum contribution of each attribute to a preference, and to estimate MARs of device failure. TT data were analyzed using interval regression. Four scenarios of LP and IDDD were compared.

RESULTS

Participants (N = 295) had a mean age of 57.7 years; most (74.2%) were diagnosed < 3 years ago. Preferences were affected by device failure risk (RAI 28.6%), administration frequency (26.4%), administration risk (19.7%), overall duration (17.8%), and appointment location (7.5%). Patients accepted a 5.6% device failure risk to reduce overall duration from 2 h to 30 min and a 3.6% risk for administration in a local clinic instead of a hospital. The average MAR of complications from implantation surgery was 29%. Patients preferred IDDD over LP in three of four scenarios.

CONCLUSION

Patients considered an IDDD as a valuable alternative to LP in multiple clinical settings.

Factors influencing refusal of lumbar puncture in children under age 10: a cross-sectional study

Background

This study aimed to investigate the factors associated with refusal of lumbar puncture (LP) in children aged 1-10 years who presented to a paediatric department in our hospital.

Methods

A sample of parents and guardians of children who presented to the paediatric department were surveyed to gather information about their educational background and decision-making processes. Attending doctors were also interviewed using a questionnaire to gather their perspectives on the reasons for LP refusal in children. Attending doctors then tried to convince the parents or guardians to see if it changed their decision.

Results

The study found that the majority of parents and guardians had a lower educational background, with over half being illiterate. Refusal of LP was seen most frequently in parents or guardians who were illiterate. The decision-making process was found to be heavily dependent on the father in a male-dominated society. Peer pressure and lack of knowledge were found to be factors that contributed to LP refusal.

Conclusion

Refusal of a LP was linked to having a lower educational background and to societal influences in this cross-sectional study of children aged 1-10 years. More than half of the parents and guardians were illiterate, indicating that they had a lower level of education. Refusing LP was influenced by a number of factors, including social pressure and a lack of information. However, these obstacles were overcome thanks to the efforts of the attending doctors who dispelled myths and reassured the parents and guardians of the necessity and safety of the procedure. Possible roadblocks include a lack of financial resources and common misconceptions about LP. These results highlight the significance of addressing educational and societal factors to enhance children's healthcare.

The Spectrum of Headache in Leptomeningeal Metastases: A Comprehensive Review with Clinical Management Guidelines

PURPOSE OF REVIEW

Headaches are a common, oftentimes debilitating symptom in patients with leptomeningeal metastases.

RECENT FINDINGS

The third edition of the International Classification of Headache Disorders provides a useful diagnostic framework for headaches secondary to leptomeningeal metastases based on the temporal relationship of headache with disease onset, change in headache severity in correlation with leptomeningeal disease burden, and accompanying neurologic signs such as cranial nerve palsies and encephalopathy. However, headaches in patients with leptomeningeal metastases can be further defined by a wide range of varying cancer- and treatment-related pathophysiologies, each requiring a tailored approach. A thorough review of the literature and expert opinion on five observed headache sub-classifications in patients with leptomeningeal metastases is provided, with attention to necessary diagnostic testing, recommended first-line treatments, and prevention strategies.