The story of dexamethasone and how it became one of the most widely used drugs in neurosurgery

Dexamethasone, a long-acting potent glucocorticoid, is one of the most widely used medications in neurosurgery. In this paper, the authors recount the history of dexamethasone's rise in neurosurgery and discuss its use in brain tumors in the context of emerging neuro-oncological immunotherapies. In 1958, Glen E. Arth synthesized a 16-alpha-methylated analog of cortisone (dexamethasone) for treatment of rheumatoid arthritis. Joseph Galicich, a neurosurgery resident at the time, applied the rheumatological drug to neurosurgery. He gave doses to patients who had undergone craniotomy for tumor removal and saw their paresis improve, midline shift resolve, and mortality rates decrease. He advocated for clinical trials and the drug became a mainstay in neurosurgery. As neuro-oncological treatments evolve to include immunotherapy, the immunosuppressive effects of dexamethasone are becoming an unwanted effect. The question then becomes: how does one treat the patient's symptoms if the only drug that has been used throughout history may become a detriment to their oncological treatment? Since its discovery, dexamethasone has maintained an impressive staying power in the field, acting as a standard drug for cerebral edema for more than 60 years. However, with the advent of immunotherapy, research is warranted to evaluate ways of treating symptomatic edema in the context of modern neuro-oncological therapies.

Charles Jacques Bouchard (1837-1915) and the Charcot-Bouchard aneurysm

Charles Jacques Bouchard was a distinguished French physician and scientist of the early 19th century. Despite his humble beginnings, Bouchard was able to achieve meteoric success within the scientific and medical fields, establishing himself as one of the most influential physician-scientists of his time. This was in part due to his superb commitment, as well as the prosperity engendered by the strong influence of his teachers, which can be seen as a testament to the importance of mentorship in medicine. Besides his myriad contributions, Bouchard is most well known for describing the Charcot-Bouchard aneurysm in 1866 alongside his mentor Jean-Martin Charcot, linking them for the first time to intracranial hemorrhage. Bouchard's thesis entitled "A Study of Some Points in the Pathology of Cerebral Hemorrhage" was regarded by some as the most original and important of all recent works on the subject of cerebral hemorrhage at the time of publication. Sadly, the great relationship Bouchard shared with his mentor Charcot would later deteriorate into perhaps one of the most well-known student-mentor quarrels in the history of medicine. Herein, the authors present a historical recollection of Bouchard's life, career, and contributions to medicine, as well as the famous controversy with Jean-Martin Charcot.

Relapse risk factors for patients with comorbid affective disorders and substance abuse disorders from an intensive treatment unit

BACKGROUND AND OBJECTIVES

The prevalence of substance use disorders (SUD), particularly involving opiates and benzodiazepines, has increased to the detriment of public health and the economy. Here, we evaluate relapse factors among the high-risk demographic of patients with SUD and comorbid affective disorders.

METHODS

A retrospective chart review of 76 patients discharged after detoxification and simultaneous psychiatric care for concomitant affective disorders and SUDs. Relapse was assessed by two independent evaluators via postdischarge chart review, which included state-wide healthcare utilization, by patient, through healthcare information exchange systems. A Cox Hazards analysis was performed to characterize relapse risk factors.

RESULTS

Benzodiazepine use, admission through the emergency department (ED) rather than direct admission, frequent ED use in the preceding year, and history of prior attendance at multiple detoxification programs were risk factors for shortened time-to-relapse. Polysubstance use and intravenous drug use prolonged time to relapse.

DISCUSSION AND CONCLUSIONS

Notable findings include the significant relapse risk associated with benzodiazepine abuse and frequent prior ED utilization. These risk factors could reflect a number of underlying mediators for relapse, including anxiety, disease burden, and malingering. Additionally, this study recapitulates the observation in other patient populations that the majority of health resource utilization is attributed to a small population of patients.

SCIENTIFIC SIGNIFICANCE

This study is the first to identify relapse predictors among dual-diagnosis affective disorder and SUD patients in survival analysis, and replicates the alarming and largely unknown effect that benzodiazepines have on increasing relapse risk.

Endoscopic biopsy of cystic intracerebral tumours

This technical note describes the application of neuroendoscopy for decompressing and obtaining tissue samples from cystic intracerebral tumours. The method provides for visualisation of the solid tumour component prior to biopsy and retains the advantages of being a burr hole procedure.

Sonographic measurement of cervical length and fetal fibronectin testing in threatened preterm labor

OBJECTIVE

In women presenting with threatened preterm labor, both fetal fibronectin and sonographic measurement of cervical length have been shown to distinguish between true and false labor. The aim of this study was to determine whether the combination of both tests provides a better prediction than the individual tests alone.

METHODS

We examined 195 women with singleton pregnancies presenting at 24-36 (median 31) weeks of gestation with regular and painful uterine contractions, intact membranes and cervical dilatation of less than 3 cm. On admission to the hospital fetal fibronectin positivity in cervicovaginal secretions was determined and transvaginal sonographic measurement of cervical length was carried out. The results were not made available to the attending obstetrician. The primary outcome measure was delivery within 7 days of presentation.

RESULTS

Delivery within 7 days occurred in 51.4% (18 of 35) of those with cervical length below 15 mm and 0.6% (1 of 160) of those with cervical length of 15 mm or more, in 21.2% (18 of 85) of the fibronectin positive group and in 0.9% (1 of 110) of the fibronectin negative group. There was a significant association between cervical length and the incidence of fibronectin positivity (r = -0.921, P = 0.003). Logistic regression analysis demonstrated that the only significant contributor to the prediction of delivery within 7 days was cervical length, with no significant contribution from fibronectin positivity, ethnic origin, maternal age, gestational age, body mass index, parity, previous history of preterm delivery, cigarette smoking, or use of tocolytics.

CONCLUSIONS

In women with threatened preterm labor assessment of fetal fibronectin in cervicovaginal secretions does not improve the prediction of delivery within 7 days provided by the sonographic measurement of cervical length.

Investigation of occiput posterior delivery by intrapartum sonography

OBJECTIVE

To investigate if occiput posterior delivery is the consequence of persistence of an initial occiput posterior position or malrotation from an initial occiput anterior or transverse position.

METHODS

This was a cross-sectional study involving transabdominal sonography to determine fetal occipital position in 918 singleton pregnancies with cephalic presentation in active labor at 37-42 weeks of gestation. The relationship between occipital position in labor and at delivery was examined.

RESULTS

The occiput was posterior in 33.0% (149/452), 33.9% (101/298) and 19.0% (32/168) of fetuses at the respective cervical dilatations of 3-5, 6-9 and 10 cm and this persisted at delivery in 21.5% (32/149), 31.7% (32/101) and 43.8% (14/32) of cases. In 70% (32/46), 91% (32/35) and 100% (14/14) of occiput posterior deliveries there was persistence from this position at 3-5, 6-9 and 10 cm of cervical dilation.

CONCLUSIONS

The majority of occiput posterior positions during labor rotate to the anterior position even at 10 cm of cervical dilatation. However, the vast majority of occiput posterior positions at delivery are a consequence of persistence of this position during labor rather than malrotation from an initial occiput anterior or transverse position.

Intrapartum sonography to determine fetal occipital position: interobserver agreement

OBJECTIVE

To investigate the interobserver agreement on the intrapartum ultrasonographic definition of the fetal occipital position.

METHODS

In 60 singleton pregnancies in labor at term the fetal occipital position was determined by transabdominal ultrasound by two appropriately trained sonographers who were not aware of each other's findings. The Bland-Altman plot was performed and the 95% limits of agreement were calculated. Logistic regression analysis was used to investigate the association between complete agreement in the fetal occipital position between the two observers and maternal and labor characteristics.

RESULTS

The two observers had complete agreement on the fetal occipital position in 22/60 (36.7%) cases and disagreement by 15 degrees and 30 degrees in 31 (51.7%) and seven (11.6%) cases, respectively. The mean of the differences between the two observers was 0.25 degrees and the 95% limits of agreement were -28.9 degrees (-32.2 degrees to -25.6 degrees) to 29.4 degrees (26.1 degrees to 32.7 degrees). There were no significant associations between complete agreement and maternal and labor characteristics.

CONCLUSION

The interobserver agreement on sonographically determined fetal occipital position during labor is within 15 degrees in nearly 90% of cases and within 30 degrees in all cases.

Laparoscopic appendicectomy at the Aga Khan Hospital, Nairobi

OBJECTIVE

To evaluate our experience of laparoscopic appendicectomy at the Aga Khan Hospital, Nairobi over a six year period from the inception of the technique and to assess its advantages and disadvantages.

DESIGN

Case series study.

SETTING

The Aga Khan Hospital, Nairobi.

PATIENTS

One hundred and six cases operated on from May 1996 to June 2002.

MAIN OUTCOME MEASURES

Clinical presentation, age and sex demographics, average hospital stay, operating time, intra-operative and post-operative complications and outcome.

RESULTS

There was a female preponderance with a female to male ratio of 2:3:1. Mean age was 30.6 years. There was a slightly more number of patients with recurrent appendicitis as opposed to the acute form. Totally laparoscopic procedure was in 39.6% of the cases, laparoscopic assisted in 45.3%. The conversion rate to an open procedure was 15.1%. Post operative port-site infection was 8.5%. No mortality was reported in these series. However there was one case which required re-operation following significant port site haemorrhage. Mean post-operative hospital stay was 2.2 days.

CONCLUSION

Laparoscopic appendicectomy is a safe procedure in well trained hands. The major advantages are less morbidity and excellent cosmesis. Discovery of other intraabdominal pathologies is possible through laparoscopy as opposed to classical appendicectomy.

Ultrasound assessment of cervical length in threatened preterm labor

OBJECTIVE

More than 70% of women presenting with threatened preterm labor do not progress to active labor and delivery. The aim of this study was to investigate the hypothesis that in women with threatened preterm labor, sonographic measurement of cervical length helps distinguish between true and false labor.

METHODS

We examined 216 women with singleton pregnancies presenting with regular and painful uterine contractions at 24-36 (mean, 32) weeks of gestation. Women in active labor, defined by the presence of cervical dilatation > or = 3 cm, and those with ruptured membranes were excluded. On admission to the hospital a transvaginal scan was performed to measure the cervical length. The subsequent management was determined by the attending obstetrician. The primary outcome was delivery within 7 days of presentation.

RESULTS

In 173 cases the cervical length was > or = 15 mm and only one of these women delivered within 7 days. In the 43 cases with cervical length < 15 mm delivery within 7 days of presentation occurred in 16 (37%) including 6/14 (42%) treated with tocolytics and 10/29 (35%) managed expectantly. Logistic regression analysis demonstrated that the only significant contributor in the prediction of delivery within 7 days was cervical length < 15 mm (odds ratio = 101, 95% CI 12-800, P < 0.0001) with no significant contribution from ethnic group, maternal age, gestational age, body mass index, parity, previous history of preterm delivery, cigarette smoking, contraction frequency or use of tocolytics.

CONCLUSIONS

In women with threatened preterm labor, sonographic measurement of cervical length helps distinguish between true and false labor.

Comparison of transvaginal digital examination with intrapartum sonography to determine fetal head position before instrumental delivery

OBJECTIVE

To investigate the accuracy of intrapartum transvaginal digital examination in defining the position of the fetal head before instrumental delivery.

PATIENTS AND METHODS

In 64 singleton pregnancies undergoing instrumental delivery the fetal head position was determined by transvaginal digital examination by the attending obstetrician. Immediately after or before the clinical examination, the fetal head position was determined by transabdominal ultrasound by a trained sonographer who was not aware of the clinical findings. The digital examination was considered to be correct if the fetal head position was within +/- 45 degrees of the ultrasound finding. The accuracy of the digital examination was examined in relation to maternal and fetal characteristics.

RESULTS

Digital examination failed to define the correct fetal head position in 17 (26.6%) cases. In 12 of 17 (70.6%) errors the difference was >/= 90 degrees and in five (29.4%) the difference was between 45 degrees and 90 degrees. The accuracy of vaginal digital examination was 83% for occiput-anterior and 54% for occiput-lateral + occiput-posterior positions. Logistic regression analysis demonstrated significant independent contributions in explaining the variance in the accuracy of vaginal examination for the station of the fetal head, the position of the fetal head and the experience of the examining obstetrician.

CONCLUSIONS

Digital examination during instrumental delivery fails to identify the correct fetal head position in about one quarter of cases.

Intrapartum sonography to determine fetal head position

OBJECTIVE

To investigate the accuracy of intrapartum transvaginal digital examination in defining the position of the fetal head.

PATIENTS AND METHODS

In 496 singleton pregnancies in labor at term, the fetal head position was determined by routine transvaginal digital examination by the attending midwife or obstetrician. Immediately before or after the clinical examination, the fetal head position was determined using transabdominal ultrasound by an appropriately trained sonographer who was not aware of the clinical findings. The digital examination was considered to be correct if the fetal head position was within 45 degrees of the ultrasound finding. The accuracy of the digital examination was examined in relation to maternal characteristics and the progress of labor.

RESULTS

The position of the fetal head was determined by ultrasound examination in all 496 cases examined. Digital examination failed to define the fetal head position in 166 (33.5%) cases and, in 330 cases where the position was determined, the findings of the digital and sonographic examinations were in agreement in only 163 (49.4%) cases. The rate of correct identification of the fetal position by digital examination increased with cervical dilatation, from 20.5% at 3-4 cm to 44.2% at 8-10 cm, and was higher if the examination was carried out by an obstetrician than a midwife (50% versus 30%) and if there was absence rather than presence of caput (33% versus 25%).

CONCLUSIONS

Routine digital examination during labor fails to identify the correct fetal position in the majority of cases.