An Evaluation of Risk Factors for Intracranial Metastases of Sarcomas: A Systematic Review and Meta-Analysis

INTRODUCTION

Sarcomas, a group of neoplasms comprising both tissue and bone soft tissue tumors, has an increasing prevalence in recent years. Prognosis significantly hinges on early detection and if not detected early may consequently metastasize. This review will be the first systematic review and meta-analysis characterizing the presentation and progression of brain metastases from bone and soft tissue cancers.

METHODS

The PubMed, Scopus, and Web of Science databases were queried to identify studies reporting the incidence of intracranial brain metastases from primary sarcoma to the present. Abstract and full-text screening of 1822 initial articles returned by preliminary search yielded 28 studies for inclusion and data extraction. Qualitative assessment of the studies were conducted in accordance with the Newcastle-Ottawa Scale criteria. Meta-analyses were applied to assess risk factors on outcomes.

RESULTS

The average age within the cohort was 27.9 years with a male and female prevalence of 59.1% and 40.9%, respectively. The odds rato for living status (dead/alive) were calculated for several risk factors - male/female [OR 1.14, 95% CI 0.62, 2.07], single/multiple metastases [OR 0.67, 95% CI 0.35, 1.28], lung metastases/not [OR 1.63, 95% CI 0.85, 3.13], surgery/no surgery [OR 0.49, 95% CI 0.20, 1.21]. The standardized mean differences for duration from diagnoses to metastases were likewise analyzed - male/female [SMD 0.13, 95% CI -0.15, 0.42], single/multiple metastases [SMD 0.11, 95% CI -0.20, 0.42], lung metastases/not [SMD -0.03, 95% CI -0.38, 0.32], surgery/no surgery [SMD 0.45, 95% CI -0.18,1.09]. The standardized mean differences for duration from metastases to death were analyzed - lung metastases/not [SMD 0.43, 95% CI -0.08, 0.95].

CONCLUSION

Our study observed no statistically significant differences in mortality rate among several patient risk factors. Consequentially, there lacks a clear answer as to whether or not an association between mortality rates exists with these patient factors. As such, it is important to continue research in brain-metastasizing sarcomas despite their relative rarity.

Immunologic Implications for Stroke Recovery: Unveiling the Role of the Immune System in Pathogenesis, Neurorepair, and Rehabilitation

Stroke is a debilitating neurologic condition characterized by an interruption or complete blockage of blood flow to certain areas of the brain. While the primary injury occurs at the time of the initial ischemic event or hemorrhage, secondary injury mechanisms contribute to neuroinflammation, disruption of the blood-brain barrier (BBB), excitotoxicity, and cerebral edema in the days and hours after stroke. Of these secondary mechanisms of injury, significant dysregulation of various immune populations within the body plays a crucial role in exacerbating brain damage after stroke. Pathological activity of glial cells, infiltrating leukocytes, and the adaptive immune system promote neuroinflammation, BBB damage, and neuronal death. Chronic immune activation can additionally encourage the development of neurologic deficits, immunosuppression, and dysregulation of the gut microbiome. As such, immunotherapy has emerged as a promising strategy for the clinical management of stroke in a highly patient-specific manner. These strategies include regulatory T cells (Tregs), cell adhesion molecules, cytokines, and monoclonal antibodies. However, the use of immunotherapy for stroke remains largely in the early stages, highlighting the need for continued research efforts before widespread clinical use.

CSF Dynamics: Implications for Hydrocephalus and Glymphatic Clearance

Beyond its neuroprotective role, CSF functions to rid the brain of toxic waste products through glymphatic clearance. Disturbances in the circulation of CSF and glymphatic exchange are common among those experiencing HCP syndrome, which often results from SAH. Normally, the secretion of CSF follows a two-step process, including filtration of plasma followed by the introduction of ions, bicarbonate, and water. Arachnoid granulations are the main site of CSF absorption, although there are other influencing factors that affect this process. The pathway through which CSF is through to flow is from its site of secretion, at the choroid plexus, to its site of absorption. However, the CSF flow dynamics are influenced by the cardiovascular system and interactions between CSF and CNS anatomy. One, two, and three-dimensional models are currently methods researchers use to predict and describe CSF flow, both under normal and pathological conditions. They are, however, not without their limitations. "Rest-of-body" models, which consider whole-body compartments, may be more effective for understanding the disruption to CSF flow due to hemorrhages and hydrocephalus. Specifically, SAH is thought to prevent CSF flow into the basal cistern and paravascular spaces. It is also more subject to backflow, caused by the presence of coagulation cascade products. In regard to the fluid dynamics of CSF, scar tissue, red blood cells, and protein content resulting from SAH may contribute to increased viscosity, decreased vessel diameter, and increased vessel resistance. Outside of its direct influence on CSF flow, SAH may result in one or both forms of hydrocephalus, including noncommunicating (obstructive) and communicating (nonobstructive) HCP. Imaging modalities such as PC-MRI, Time-SLIP, and CFD model, a mathematical model relying on PC-MRI data, are commonly used to better understand CSF flow. While PC-MRI utilizes phase shift data to ultimately determine CSF speed and flow, Time-SLIP compares signals generated by CSF to background signals to characterizes complex fluid dynamics. Currently, there are gaps in sufficient CSF flow models and imaging modalities. A prospective area of study includes generation of models that consider "rest-of-body" compartments and elements like arterial pulse waves, respiratory waves, posture, and jugular venous posture. Going forward, imaging modalities should work to focus more on patients in nature in order to appropriately assess how CSF flow is disrupted in SAH and HCP.

Breastfeeding: it is worth trying with the second baby

Mothers who experience breastfeeding difficulties with their first babies and give up breastfeeding are less likely to breastfeed subsequent babies than mothers who do not experience such difficulties. We carried out a longitudinal study of 22 mothers in which milk output was measured at 1 week and 4 weeks after giving birth to their first and second babies. Significantly more breast milk was produced at 1 week for the second lactation (an increase of 31% [95% CI 11-51%]) and the net increase was greatest for those with the lowest milk output on the first occasion (90% [30-149%]). They spent less time feeding their second baby (a decrease of 20% [-34 to -5%]). This increased efficiency of milk transfer was also evident at 4 weeks. Health professionals should encourage women to breastfeed all their children, whatever their experience with their first child.

A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding

BACKGROUND

Human breastmilk provides complete nutrition for infants and helps protect against certain childhood diseases. Despite this, rates of initiation of breastfeeding in the UK remain low relative to other countries. In 'Our healthier nation' action report, the government has highlighted the promotion of breastfeeding in order to assist improvements in health and to reduce the health inequalities of mothers and children in the UK.

OBJECTIVES

The primary aim of this systematic review was to evaluate existing evidence to identify which promotion programmes are effective at increasing the number of women who start to breastfeed. In addition, the review aimed to assess the impact of such programmes on the duration and/or exclusivity of breastfeeding and the intermediate and process outcomes. Where the strength and quality of the evidence permitted, the review aimed to identify implications for practice within the UK and priority areas for future research.

METHODS

DATA SOURCES

A range of electronic databases were searched from inception to November 1998, several relevant journals were hand-searched, and references of retrieved papers were examined. Relevant experts, organisations and lay groups were contacted to help identify further published or unpublished material. Additionally, an expert panel was consulted.

SELECTION CRITERIA

Four types of criteria were used to select eligible studies for this review: STUDY DESIGN - randomised controlled trials (RCTs), non-RCTs with concurrent controls, and before-after studies (cohort or cross-sectional). PARTICIPANTS - pregnant women, mothers in the immediate postpartum period before the first breastfeed, any participant linked to pregnant women or new mothers, or any participant who may breastfeed in the future, or be linked to a breastfeeding woman in the future. INTERVENTIONS - any type of intervention designed to promote the uptake of breastfeeding was included; control groups could receive an alternative breastfeeding promotion programme or standard care. OUTCOMES - the primary outcome was initiation of breastfeeding; secondary outcomes (duration and exclusivity of breastfeeding) were included if initiation was reported in the same study; intermediate and process outcomes were also included, and need not necessarily be associated with reported initiation rates. DATA EXTRACTION AND VALIDITY ASSESSMENT: Data were extracted into structured tables. All included studies were checked against a comprehensive methodological checklist. Different checklists were used for RCTs, non-RCTs and before-after studies. Data extraction and validity assessment were independently checked by a second reviewer.

DATA SYNTHESIS

The studies were grouped according to intervention type, and were combined using a narrative synthesis. For individual RCTs and non-RCTs reporting initiation of breastfeeding, relative risks with associated 95% confidence intervals were estimated, with calculations performed on an intention-to-treat basis where possible. Pooling of relative risks was considered inappropriate owing to the lack of similarity across the studies.

RESULTS

A total of 59 studies met the selection criteria, comprising 14 RCTs, 16 non-RCTs and 29 before-after studies. Interventions were grouped into the following categories: health education, health sector initiatives (HSI) - general, HSI - Baby Friendly Hospital Initiative (BFHI), HSI - training of health professionals, HSI - US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), HSI - social support from health professionals, peer support, media campaigns, multifaceted interventions. In many cases, studies were dissimilar in terms of the type of intervention(s), participants and the definitions of outcomes. Methodological problems of some studies also limited interpretation of findings. (ABSTRACT TRUNCATED)

Interventions for influencing sleep patterns in exclusively breastfed infants

BACKGROUND

The difference between night and day may be reinforced in young babies by offering a 'focal feed' between 10pm and midnight and gradually lengthening the intervals between night-time feeds by a variety of other activities (such as nappy changing, re-swaddling and walking with the infant).

OBJECTIVES

The objective of this review was to assess the effects of using a structured training programme to teach exclusively breastfed infants to sleep through the night by eight weeks old.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Acceptably controlled trials of a structured programme accentuating the difference between night and day compared with no intervention in first time parents of singleton babies, with mothers intending to exclusively breastfeed their infants for at least eight weeks post-partum.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers.

MAIN RESULTS

One trial involving 33 couples was included. More infants in the treatment group were sleeping throughout the night by eight weeks of age than in the control group (odds ratio 0.04, 95% confidence interval 0.01 to 0.21).

REVIEWER'S CONCLUSIONS

There is some evidence to show that first time parents using a structured sleeping programme can teach their babies to sleep through the night by eight weeks of age.

Oxytocin for promoting successful lactation

BACKGROUND

A rise in the concentration of oxytocin causes contraction of cells around the alveoli and milk ducts, in preparation for suckling. Lactation failure may result from insufficient oxytocin.

OBJECTIVES

The objective of this review was to assess the effects of using oral or nasal oxytocin on lactation.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

Randomised and quasi-randomised trials of variable doses of oxytocin and different methods of administration versus placebo in breastfeeding women using oxytocin to augment lactation.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by two reviewers.

MAIN RESULTS

Four trials of 639 women were included. There was potential for significant bias in these trials. Restricted breastfeeding schedules may have contributed to inadequate production of milk by the participants. Sublingual and buccal preparations of oxytocin were associated with an increase in milk production. Oxytocin did not appear to increase the incidence of breast pain and 100 international units of oxytocin appeared to be slightly more beneficial than 10 international units.

REVIEWER'S CONCLUSIONS

An appropriate dose of sublingual or buccal oxytocin may help augment lactation where necessary. However if women are encouraged and supported with unrestricted breastfeeding, the need for oxytocin would probably be diminished.

Nursing frequency and the energy intake from breast milk and supplementary food in a rural Thai population: a longitudinal study

A group of 60 infants representative of a rural Thai population were studied longitudinally over the first year of life. Their breast milk intake, supplementary food intake and nursing patterns were measured for 2 consecutive days at about 15, 45, 90, 180, 270 and 360 days of age. For the sample as a whole, the estimated peak value for energy intake from breast milk was 529 kcal (2213 kJ) and occurred at 34 days post-partum. Thereafter milk intake declined, with 40% of infants fully weaned by the end of the first year. Supplements were introduced early, with 15% of infants supplemented by 2 weeks and 68% by 6 weeks. Higher levels of supplementation were associated with lower breast milk intake. In addition there was an independent positive effect of nursing patterns (number of breast feeds per day). Interaction terms show that both supplementary feeding and number of feeds have quantitatively different effects at different ages: breast milk intake varies more with level of supplementation in younger infants than in older infants, and varies more with number of feeds in older infants than in younger infants. Higher peak levels of breast milk intake were followed by a steeper decline, and infants who took more breast milk at 15 days were more likely to be fully weaned by their first birthday.

The Chiang Mai lactation project: study design and implementation

The Chiang Mai lactation project is a longitudinal field study of human lactation carried out among northern Thai women living in the Sanpatong area of Chiang Mai Province. Its aim was to measure the volume and composition of breast milk transferred from mothers to their infants in the first year postpartum, and to relate it to predictors of milk production, and to the growth of the child. Breast milk and supplementary food intake, and nursing patterns, were recorded over two consecutive 24-hour periods six times during the first year. Samples of breast milk and of supplementary foods were analysed for energy and protein. Supplementary foods were also analysed for bacterial contamination. The growth of the child was measured, and health assessed using a combination of health diaries and examination by a physician. Recruitment to the study was excellent. After recruitment, two subjects left the study area, but otherwise only two dropped out, so complete sets of data covering these variables are available for 58 of the 62 recruited subjects.

Sucking patterns of human babies on the breast

Twenty-seven 5--8-day-old babies were filmed during normal breast feeding (one feed each). Sucking patterns were determined from the film from a total sample of 17,676 sucks. Intersuck interals fell on two distributions: one of intervals between sucks during bursts of sucking (1.3 sec and less), and the other of rests between bursts of sucking (1.3 to greater than 12 sec). As the milk flow dropped towards the end of the feed on each breast, the sucking rate within bursts increased (P less than 0.05), but there were more (P less than 0.001) and longer (P less than 0.001) rests between bursts of sucking. This study provides normative data on a normal population for use in studies of breast feeding.