Risk factors for perianeurysmal vasogenic oedema (pavo) following embolization therapy: literature review

Perianeurysmal vasogenic oedema (PAVO) is a rare complication associated post-embolisation of intracranial aneurysms. The prevalence, risk factors predisposing to susceptibility, and pathologic mechanisms underlying this process are not clearly understood. Since this complication may be associated with poor clinical outcomes, the authors designed this study to describe possible risk factors, underlying mechanisms, and management of PAVO through published case reports. Developing a priori protocol according to PRISMA guidelines, we searched MEDLINE/PubMed, Embase and Web of Science to identify case studies and reports of adult patients with intracranial aneurysms who developed perianeurysmal oedema following coil embolization therapy. Data extracted from these studies included patient demographics, aneurysm characteristics, coil type, PAVO characteristics, treatment, and outcomes. Quality was assessed using a standardized tool. 21 eligible studies of acceptable quality were identified, comprising 40 unique cases from 9 countries. The mean patient age was 56.4 years and 25 (62.5%) were female. Aneurysm size ranged from 6 to 30 mm, with a mean size of 15.2 mm; only 6 (15%) of cases were giant intracranial aneurysm (≥ 25 mm). The more frequent locations of intracranial aneurysms associated with PAVO were the ICA (50%) and posterior circulation (32.5%), with 7.5% and 10% of cases occurring in MCA and anterior circulation, respectively. 16 cases (40%) were treated with bare platinum coils, and 14 (35%) with a combination of BPCs and bioactive coils; in 10 cases (25%), the coil type was not mentioned. PAVO presented between 0 days and 8 years of coil embolization, with 23 (57.5% cases) presenting symptomatically in relation to brain region affected. Management strategies for PAVO included conservative, steroids, re-embolization, clipping, stenting, parent artery occlusion either as monotherapy or as combination therapy. Of reported studies, 26 treated cases (65%) resolved, with 8 (20%) remaining stable, and 4 (10%) deteriorating. PAVO can be associated with small or large intracranial aneurysms, bare and bioactive platinum coils, and all regions of the intracranial circulation. The understanding of the risk factors of this complication lies in the underlying mechanisms, which will ultimately guide appropriate patient follow-up and subsequent optimal management.

Irrigation area, efficiency and water storage mediate the drought resilience of irrigated agriculture in a semi-arid catchment

We examined the effects of hydrological variables such as irrigation area, irrigation efficiency and water storage on the resilience of (mostly commercial) irrigated agriculture to drought in a semi-arid catchment in South Africa. We formulated a conceptual framework termed 'Water, Efficiency, Resilience, Drought' (WERD) and an accompanying spreadsheet model. These allow the resilience of irrigated agriculture to drought to be analysed via water accounts and a key resilience indicator termed Days to Day Zero (DDZ). This represents the number of days that a pre- and within-drought supply of catchment water available to irrigation is withdrawn down to zero in the face of a prolonged drought. A higher DDZ (e.g. >300 days) indicates greater resilience whilst a lower DDZ (e.g. <150 days) signals lower resilience. Drought resilience arises through land and water management decisions underpinned by four types of resilience capacities; absorptive, adaptive, anticipative and transformative. For the case study, analyses showed that irrigators, with currently approximately 23,000 ha under irrigation, have historically absorbed and adapted to drought events through construction of water storage and adoption of more efficient irrigation practices resulting in a DDZ of 260 days. However, by not fully anticipating future climate and water-related risks, irrigators are arguably on a maladaptive pathway resulting in water supply gains, efficiency and other practices being used to increase irrigation command areas to 28,000 ha or more, decreasing their capacity to absorb future droughts. This areal growth increases water withdrawals and depletion, further stresses the catchment, and reduces future DDZs to approximately 130 days indicating much lower drought resilience. Our approach, supported by supplementary material, allows stakeholders to understand the resilience consequences of future drought in order to; reconcile competition between rising water demands, consider new water storage; improve agricultural and irrigation planning; and enhance catchment governance.

Non-cardiac Manifestations in Adult Patients With Mucopolysaccharidosis

Mucopolysaccharidoses (MPS) are a heterogeneous group of disorders that results in the absence or deficiency of lysosomal enzymes, leading to an inappropriate storage of glycosaminoglycans (GAGs) in various tissues of the body such as bones, cartilage, heart valves, arteries, upper airways, cornea, teeth, liver and nervous system. Clinical manifestations can become progressively exacerbated with age and affect their quality of life. Developments in advanced supportive treatment options such as enzyme replacement therapy (ERT), hematopoietic stem cell transplantation (HSCT) may have improved patients' life span. Adult MPS patients require specialist clinical surveillance long-term. In many cases, in addition to the MPS-related health problems, they may develop age-related complications. Considering the complexity of their clinical manifestations and lack of guidelines on the management of adult MPS disorders, multispecialty and multidisciplinary teams' care is essential to diagnose and treat health problems that are likely to be encountered. This review presents non-cardiac clinical manifestations, their pathophysiology, management and long-term outcomes in adult MPS patients.

The role of artificial intelligence in paediatric neuroradiology

Imaging plays a fundamental role in the managing childhood neurologic, neurosurgical and neuro-oncological disease. Employing multi-parametric MRI techniques, such as spectroscopy and diffusion- and perfusion-weighted imaging, to the radiophenotyping of neuroradiologic conditions is becoming increasingly prevalent, particularly with radiogenomic analyses correlating imaging characteristics with molecular biomarkers of disease. However, integration into routine clinical practice remains elusive. With modern multi-parametric MRI now providing additional data beyond anatomy, informing on histology, biology and physiology, such metric-rich information can present as information overload to the treating radiologist and, as such, information relevant to an individual case can become lost. Artificial intelligence techniques are capable of modelling the vast radiologic, biological and clinical datasets that accompany childhood neurologic disease, such that this information can become incorporated in upfront prognostic modelling systems, with artificial intelligence techniques providing a plausible approach to this solution. This review examines machine learning approaches than can be used to underpin such artificial intelligence applications, with exemplars for each machine learning approach from the world literature. Then, within the specific use case of paediatric neuro-oncology, we examine the potential future contribution for such artificial intelligence machine learning techniques to offer solutions for patient care in the form of decision support systems, potentially enabling personalised medicine within this domain of paediatric radiologic practice.

Thresholds of acidification impacts on macroinvertebrates adapted to seasonally acidified tropical streams: potential responses to extreme drought-driven pH declines

Background

Drought-driven acidification events of increasing frequency and severity are expected as a consequence of climate change, and these events may expose macroinvertebrate taxa to increased acidification beyond their tolerance levels. Recent work in lowland Costa Rica has shown that poorly-buffered tropical streams exhibit natural seasonal variation in pH, with extremely low levels (<4.5) after extreme dry seasons). Our goal was to determine the threshold of pH effects on survival of three tropical stream macroinvertebrate taxa.

Methods

We conducted laboratory mesocosm experiments to determine acidification effects (using diluted HCl) on three focal macroinvertebrate taxa collected from a poorly-buffered stream at La Selva Biological Station: (1) mayfly naiads (Ephemeroptera: Leptophlebiidae: Traverella holzenthali), (2) adult shrimp (Decapoda: Palaemonidae: Macrobrachium olfersii), and (3) larval midges (Diptera: Chironomidae). We also compared the effect of pH on survival and growth rates of larval midges from a poorly-buffered (pH 4.3-6.9) vs. a naturally well-buffered (pH 5.1-6.9) stream.

Results/Discussion

Mayfly and shrimp survival decreased between pH 4.0 and 3.5, overlapping with the range of lowest pH levels (3.6-4.0) recorded during a previous extreme El Niño Southern Oscillation event in 1998 and suggesting that increasingly extreme acidification events induced by climate change may negatively affect their survival. In contrast, survival of larval midges was unaffected by pH regimes at/above 3.5, indicating tolerance to pH levels experienced in poorly-buffered stream during seasonal acidification, which has presumably occurred over millennia. These findings highlight the potential importance of historical pH regimes in structuring macroinvertebrate communities. These results are relevant not only to lowland Neotropical streams, but also signal the need for further research in lotic ecosystems worldwide where drought-driven pH declines have been documented or are probable in the future.

Manchester Arena Attack: management of paediatric penetrating brain injuries

PURPOSE

The Manchester Arena bombing on 22 May 2017 resulted in 22 deaths and over 160 casualties requiring medical attention. Given the threat of modern- era terrorist attacks in civilian environments, it is important that we are able to anticipate and appropriately manage neurological injuries associated with these events. This article describes our experience of managing paediatric neurosurgical blast injuries, from initial triage and operative management to longer-term considerations.

MATERIALS AND METHODS

Case study and literature review.

RESULTS

Paediatric traumatic and penetrating brain injury patients often make a good neurological recovery despite low GCS at time of injury; this should be accounted for during triage and operative decision making in major trauma, mass casualty events. Conservative management of retained shrapnel is advocated in view of low long-term infection rates with retained shrapnel and worsened neurological outcome with shrapnel retrieval. All penetrating brain injuries should receive a prolonged course of broad-spectrum antibiotics and undergo long term follow-up imaging to monitor for the development of cerebral abscesses. MRI should never be utilised in penetrating brain injury cases, even in the absence of macroscopically visible fragments, due to the effect of MRI ferromagnetic field torque on shrapnel fragments. Anti-epileptic drugs should only be prescribed for the initial seven days after injury, as continuing beyond this does not incur any benefit in the reduction of long term post-traumatic epilepsy.

CONCLUSION

All receiving neurosurgical units should become familiar with optimum management of these thankfully rare, but complex injuries from their initial presentation to long term follow up considerations. All neurosurgical units should have well-rehearsed local plans to follow in the event of such incidents, ensuring timely deliverance of appropriate neurosurgical care in such extreme settings.

Renal medullary carcinoma and its association with sickle cell trait: a case report and literature review

Renal medullary carcinoma (rmc) is a rare and aggressive renal malignancy that usually presents at an advanced stage, has a poor prognosis, and is associated with sickle cell trait. We present a case of rmc including radiologic and pathology findings, treatment, and outcome. A review of the literature is also presented, with an emphasis on the association of rmc with sickle cell trait, which was an unknown diagnosis in our patient preoperatively.

P36 A 1 and 5 year outcome analysis of epilepsy surgery in adults and children

Objectives

To evaluate the efficacy of epilepsy surgery at 1 year following surgery and to assess sustainability of seizure control at 5 years post-surgery. To find prognostic factors for good surgical outcomes.

Design

Retrospective case notes analysis.

Subjects

82 consecutive patients operated on for epilepsy by a single surgeon between 2008–2013.

Methods

Patients were identified in pre-existing hospital databases and included if 5 year follow-up was available. Their clinical records were accessed via the electronic patient records system at each site. The Engel Classification was used to grade seizure outcome at years 1 and 5 post-surgery. We classified Engel Class I and II as a good outcome and Engel class III and IV as a poor outcome. Case notes were also examined to find prognostic factors for a good long-term surgical outcome.

Results

86.4% of patients had a good outcome 1 year post-surgery and 77.9% had a good outcome at 5 years. The surgery site (temporal or otherwise) and the presence of a good outcome at year one were found to contribute significantly to odds of a good outcome at year 5. The ability to wean off medication is also commonly an important factor for patients and 24.4% of patients were AED free at 5 years.

Conclusions

Surgery is an effective management option for intractable epilepsy in suitably selected patients with complete or near complete seizure cessation in about 80% of the patients and about a quarter of the patients no longer requiring AEDs.

TP3-2 Epilepsy surgery outcomes in a paediatric population – a single centre 10 year experience

Objectives

To analyse the efficacy of epilepsy surgery in reducing the burden of seizures in a paediatric population – a single centre 10 year experience.

Design

Single centre retrospective review of medical records.

Subjects

74 consecutive paediatric patients who underwent epilepsy surgery between 2008–2017 by one neurosurgeon at a single centre.

Methods

Seizure history, pre-operative investigations, surgical interventions, seizure outcomes, complications and long term anti-epileptic drug (AED) use were evaluated. Seizure outcomes at 1 year post surgery to the last available follow up (up to 5 years) were documented and classified using the Engel System. Engel I and II were classified as a good seizure outcome and Engel III and IV were classified as a poor seizure outcome.

Results

The mean duration of follow up was 41 months. 62.2% of patients achieved seizure freedom (Engel I) at their latest follow up, with 82.4% of patients achieving a good seizure outcome (Engel I/II). 13.5% of patients achieved worthwhile improvement (Engel III) and only 4.1% of patients had no worthwhile improvement in seizure burden (Engel IV). More favourable outcomes were observed in children with temporal lobe epilepsy. Post-surgery AED use was reduced or discontinued in 41.4% of all patients; 41.4% of the 29 patients with AED data at their 5 year follow up were completely free of AEDs.

Conclusions

Epilepsy surgery is an efficacious treatment with low morbidity and no mortality that is underutilised in children with medically intractable seizures.

Global patterns and drivers of ecosystem functioning in rivers and riparian zones

River ecosystems receive and process vast quantities of terrestrial organic carbon, the fate of which depends strongly on microbial activity. Variation in and controls of processing rates, however, are poorly characterized at the global scale. In response, we used a peer-sourced research network and a highly standardized carbon processing assay to conduct a global-scale field experiment in greater than 1000 river and riparian sites. We found that Earth's biomes have distinct carbon processing signatures. Slow processing is evident across latitudes, whereas rapid rates are restricted to lower latitudes. Both the mean rate and variability decline with latitude, suggesting temperature constraints toward the poles and greater roles for other environmental drivers (e.g., nutrient loading) toward the equator. These results and data set the stage for unprecedented "next-generation biomonitoring" by establishing baselines to help quantify environmental impacts to the functioning of ecosystems at a global scale.

A nine-year review of medicolegal claims in neurosurgery

INTRODUCTION

Neurosurgery remains among the highest malpractice risk specialties. This study aimed to identify areas in neurosurgery associated with litigation, attendant causes and costs.

METHODS

Retrospective analysis was conducted of 42 closed litigation cases treated by neurosurgeons at one hospital between March 2004 and March 2013. Data included clinical event, timing and reason for claim, operative course and legal outcome.

RESULTS

Twenty-nine claims were defended out of court and twelve were settled out of court. One case required court attendance and was defended. Of the 42 claims, 28, 13 and 1 related to spinal (0.3% of caseload), cranial (0.1% of caseload) and peripheral nerve (0.07% of caseload) surgery respectively. The most common causes of claims were faulty surgical technique (43%), delayed diagnosis/misdiagnosis (17%), lack of information (14%) and delayed treatment (12%), with a likelihood of success of 39%, 29%, 17% and 20% respectively. The highest median payouts were for claims against faulty surgical technique (£230,000) and delayed diagnosis/misdiagnosis (£212,650). The mean delay between clinical event and claim was 664 days.

CONCLUSIONS

Spinal surgery carries the highest litigation risk versus cranial and peripheral nerve surgery. Claims are most commonly against faulty surgical technique and delayed diagnosis/misdiagnosis, which have the highest success rates and payouts. In spinal surgery, the most common cause of claims is faulty surgical technique. In cranial surgery, the most common cause is lack of information. Claims may occur years after the clinical event, necessitating thorough contemporaneous documentation for adequate future defence. We emphasise thorough patient consultation and meticulous surgical technique to minimise litigation in neurosurgical practice.

Environmental and organismal predictors of intraspecific variation in the stoichiometry of a neotropical freshwater fish

The elemental composition of animals, or their organismal stoichiometry, is thought to constrain their contribution to nutrient recycling, their interactions with other animals, and their demographic rates. Factors that affect organismal stoichiometry are generally poorly understood, but likely reflect elemental investments in morphological features and life history traits, acting in concert with the environmental availability of elements. We assessed the relative contribution of organismal traits and environmental variability to the stoichiometry of an insectivorous Neotropical stream fish, Rivulus hartii. We characterized the influence of body size, life history phenotype, stage of maturity, and environmental variability on organismal stoichiometry in 6 streams that differ in a broad suite of environmental variables. The elemental composition of R. hartii was variable, and overlapped with the wide range of elemental composition documented across freshwater fish taxa. Average %P composition was ∼3.2%(±0.6), average %N∼10.7%(±0.9), and average %C∼41.7%(±3.1). Streams were the strongest predictor of organismal stoichiometry, and explained up to 18% of the overall variance. This effect appeared to be largely explained by variability in quality of basal resources such as epilithon N∶P and benthic organic matter C∶N, along with variability in invertebrate standing stocks, an important food source for R. hartii. Organismal traits were weak predictors of organismal stoichiometry in this species, explaining when combined up to 7% of the overall variance in stoichiometry. Body size was significantly and positively correlated with %P, and negatively with N∶P, and C∶P, and life history phenotype was significantly correlated with %C, %P, C∶P and C∶N. Our study suggests that spatial variability in elemental availability is more strongly correlated with organismal stoichiometry than organismal traits, and suggests that the stoichiometry of carnivores may not be completely buffered from environmental variability. We discuss the relevance of these findings to ecological stoichiometry theory.

Ecological forecasts: an emerging imperative

Planning and decision-making can be improved by access to reliable forecasts of ecosystem state, ecosystem services, and natural capital. Availability of new data sets, together with progress in computation and statistics, will increase our ability to forecast ecosystem change. An agenda that would lead toward a capacity to produce, evaluate, and communicate forecasts of critical ecosystem services requires a process that engages scientists and decision-makers. Interdisciplinary linkages are necessary because of the climate and societal controls on ecosystems, the feedbacks involving social change, and the decision-making relevance of forecasts.

Immunogenicity and pathogenicity of temperature-sensitive modified respiratory syncytial virus in adult volunteers

Single temperature-sensitive (ts) mutants of a subgroup A strain of respiratory syncytial (RS) virus whose multiplication is restricted at 39 degrees C in MRC-6 cells and double ts mutants that are restricted at 38 degrees C, were obtained following mutagenesis using 5-fluorouracil and acridine-like compounds. Isolation and propagation of the parental RSS-2 strain of RS virus and its derived ts mutants were carried out entirely in MRC-5 human diploid cells. The immunogenicity and disease-producing ability of four of these mutants and the parental unmodified strain have been assessed by intranasal administration into groups of about 20 adult volunteers. The results of these trials indicate that the capacity of the parental RSS-2 strain to produce upper respiratory tract infection in adults was not diminished by limited propagation in MRC-5 cells. The mutants on the other hand were impaired in this respect to varying extents. The double mutant tslB in particular has characteristics that suggest that it may be suitable for further development as a live RS virus vaccine. It retained near normal immunogenicity and replicative ability in the upper respiratory tract, while exhibiting greatly reduced disease-producing potential.

The non-entrained life of a young gentleman at Oxford

Sleep logs over 9 months document the delayed sleep phase of a healthy male student at Oxford. The lack of any imperative zeitgebers also permits the rest-activity cycle to exhibit very long (circabidian) days similar to those seen under conditions of temporal isolation. No psychopathology or subjective distress was associated with this unusual rest-activity cycle: It was a preferred life-style.