The SOS-SAH questionnaire in clinical practice: a multi-method evaluation study

BACKGROUND

In patients with mild disabilities after aneurysmal subarachnoid hemorrhage (aSAH), invisible symptoms might be easily overlooked during consultations in the outpatient clinic. We hypothesize that the Questionnaire for the Screening of Symptoms in aneurysmal Subarachnoid Hemorrhage (SOS-SAH), a disease-specific patient-reported outcome measure, might aid in screening for symptoms after aSAH. The objective of this explorative study is to evaluate the perceived impact of using the SOS-SAH in daily clinical practice for patients after aSAH, as well as to explore potential barriers to further implementation.

METHODS

This multi-method study consists of a quantitative and a qualitative component. To evaluate differences in quality of care, a patient experience survey was sent to patients receiving usual care and to patients who received the SOS-SAH. A multiple linear regression model was applied, with the intervention group and case mix adjusters as independent variables. We described differences in the number of symptoms discussed between patients receiving usual care and those receiving care post-implementation. Following implementation, 16 patients and 6 healthcare professionals were interviewed about their perceptions concerning the impact of and barriers to using the SOS-SAH. A thematic analysis was performed to identify the main themes.

RESULTS

The survey did not reveal any differences between the usual-care group and the post-implementation group on the scales of the patient experience survey. After implementation of the SOS-SAH, the number of symptoms discussed during consultation did not increase. The interviews suggest that the SOS-SAH may improve the preparation of patients by providing them with greater insight into their complaints and by raising issues for the consultation. It could also enhance the structure and efficiency of consultation, in addition to improving communication about issues that matter to patients. All patients and healthcare professionals recommended continuing the use of the SOS-SAH in daily practice.

CONCLUSIONS

Although no quantitative improvements were found in patient experience and symptoms discussed during consultation, implementation of the SOS-SAH could aid in screening for symptoms in patients after aSAH, and it might have a positive influence on patient preparation, while helping to structure consultations between patients and healthcare professionals.

WEB Treatment of Ruptured Intracranial Aneurysms: Long-Term Follow-up of a Single-Center Cohort of 100 Patients

BACKGROUND AND PURPOSE

The Woven EndoBridge device (WEB) was introduced for the intrasaccular treatment of wide-neck aneurysms without the need for adjunctive devices. We used the WEB as a primary treatment for 100 ruptured aneurysms regardless of neck size or location. In this study, we present the long-term follow-up of 78 surviving patients.

MATERIALS AND METHODS

Between February 2015 and April 2017, one hundred ruptured aneurysms were treated with the WEB. For surviving patients, angiographic and clinical follow-up was scheduled at 3 months, and 3T MRA and clinical follow-up, at 6, 12, 36, and 60 months. Of 100 patients, 18 died during hospital admission, and in 4, the ruptured aneurysm was additionally treated. The remaining 78 patients had a mean follow-up of 51 months (median, 52 months; range, 5-84 months). There were 57 women and 21 men, with a mean age of 58.5 years (median, 59 years; range, 24-80 years). Of 78 aneurysms with long-term follow-up, 52 (66%) had a wide neck.

RESULTS

Of 78 ruptured aneurysms, 56 (72%) remained completely occluded and 17 (22%) had a stable small neck remnant. Five of 78 aneurysms (6%; 95% CI, 2.4%-14.5%) reopened during follow-up and were additionally treated. There were no rebleeds during follow-up.

CONCLUSIONS

Treatment of ruptured aneurysms with the WEB was safe and effective and has long-term results comparable with those of simple coiling of small-neck aneurysms. The WEB proved to be a valuable alternative to coils for both wide- and small-neck ruptured aneurysms without the need for stents, balloons, or antiplatelet therapy.

Tentorial Dural Arteriovenous Fistulas: A Single-Center Cohort of 12 Patients

Objective

Tentorial dural arteriovenous fistulas usually drain into cortical veins and often present with hemorrhage. Treatment goal is occlusion of the draining vein, either by surgery or endovascular techniques. We present the multimodality treatment results of 12 patients with tentorial dural arteriovenous fistulas.

Materials and Methods

Between January 2007 and January 2017, 12 consecutive patients with tentorial dural arteriovenous fistulas were treated. There were 11 men and 1 woman with a mean age of 62 years (range 44–85). Clinical presentation was hemorrhage in 8 (67%), pulsatile tinnitus in 2 (17%) and an incidental finding in 2 (17%). The fistula location was at the tentorium cerebelli in 5 (42%), the torcula Herophilii in 4 (33%) and petroclival in 3 (25%).

Results

In 11 patients, arterial embolization with Onyx or PHIL was the primary treatment. Complete obliteration was achieved in one session in 5 (45%) and in 2 sessions in 4 (36%). In 2 patients additional surgery was needed. Primary surgery was performed in 1 patient followed by endovascular coil occlusion via the venous route. One patient with exclusive pial feeders from the posterior inferior cerebellar artery had a clinically silent P3 occlusion during trans arterial embolization. Finally, all 12 fistula were completely occluded, confirmed with angiography after 8–12 weeks. There were no permanent procedural complications.

Conclusion

Patients with tentorial dural arteriovenous fistulas were effectively and safely cured with a strategy of endovascular treatment with various techniques and surgery. Surgical and endovascular techniques are complementary in the treatment of these challenging vascular disorders.

WEB Treatment of Ruptured Intracranial Aneurysms: A Single-Center Cohort of 100 Patients

BACKGROUND AND PURPOSE

The Woven EndoBridge device was recently introduced for the intrasaccular treatment of wide-neck aneurysms without the need for adjunctive devices. We present our results of the primary treatment of ruptured aneurysms with the Woven EndoBridge regardless of location or neck size.

MATERIALS AND METHODS

Between February 2015 and April 2017, 100 ruptured aneurysms were selectively treated with the Woven EndoBridge. No supporting stents or balloons were used. There were 71 women treated (mean patient age, 59 years; median age, 60 years; range, 23-82 years).

RESULTS

The mean aneurysm size was 5.6 mm (range, 3-13 mm), and 42 aneurysms were ≤4 mm. Sixty-six aneurysms (66%) had a wide neck, defined as ≥4 mm or a dome-neck ratio ≤1.5. There was 1 procedural rupture without sequelae. In 9 patients (9%), thromboembolic complications occurred. One poor grade patient died; neurologic deficits remained in 3. Overall treatment-related morbidity-mortality was 4% (4 of 100; 95% CI, 1.2%-10.2%).Two of 100 aneurysms were initially incompletely occluded and were additionally treated early after initial intervention. Of 80 eligible patients, 74 (93%) had 3-month angiographic follow-up. Fifty-four aneurysms (73%) were completely occluded, 17 (23%) had a small neck remnant, and 3 (4%) were incompletely occluded. One patient was additionally treated with a second Woven EndoBridge, and in 2 patients, additional treatment is scheduled. The overall reopening/retreatment rate was 6.8% (5 of 74; 95% CI, 2.6%-15.2%). There were no rebleeds during follow-up.

CONCLUSIONS

Treatment of small ruptured aneurysms with the Woven EndoBridge was safe and effective. The Woven EndoBridge proved to be a valuable alternative to coils without the need for stents or balloons.

Treatment of cranial dural arteriovenous fistulas with exclusive cortical venous drainage: A single-center cohort of 35 patients

Background and purpose Dural arteriovenous fistulas (DAVFs) with cortical venous drainage often present with hemorrhage or neurological deficits and prompt treatment is indicated. Disconnection of the draining vein is considered curative. We present the multimodality treatment results of 35 patients with cranial DAVFs with exclusive cortical venous drainage. Materials and methods Between January 2010 and January 2017, 35 consecutive patients with cranial dural fistulas with exclusive cortical venous drainage were treated. There were 27 men and eight women, mean age 68 years (range 45-87). Clinical presentation was hemorrhage in 23 (66%), pulsatile bruit in two (6%), seizures in one (3%) and blurred vision in one (3%). In eight patients (22%), the DAVF was an incidental finding. Location of the DAVFs was convexity in 25 (71%), posterior fossa in eight (23%) and tentorium in two (6%). Results Surgery was performed in four patients with anterior cranial fossa fistulas and in one patient with a tentorial dural fistula. In 30 patients, embolization with Onyx via the arterial route was the primary treatment with complete obliteration in one session in 25 patients. Additional surgical or endovascular sessions were necessary in five patients after incomplete embolization and in one patient after incomplete surgery. Obliteration was confirmed with angiography after three months. There were no procedural complications. Conclusions Patients with dural fistulas with cortical venous drainage were cured with a strategy of arterial endovascular treatment with Onyx and surgery. These techniques were either primarily successful or complementary. There were no complications of treatment.

Spinal dural fistulas without swelling and edema of the cord as incidental findings

SUMMARY

SDAVFs cause hypertension and hence outflow obstruction in the perimedullary venous system resulting in swelling and edema of the cord followed by dysfunction. Clinical presentation is usually with gradual progressive paraparesis, numbness, and sphincter problems. MR imaging typically demonstrates the dilated perimedullary veins and the swelling and edema of the cord. During the past few years, we incidentally found an SDAVF on MR imaging with dilated perimedullary veins but without swelling and edema of the cord in 5 patients with unrelated presenting clinical symptoms. Spinal angiography confirmed the presence of an SDAVF in all 5 patients. Although the indication was considered questionable, eventually all 5 fistulas were endovascularly or surgically treated, resulting in normalization of the MR images.

Discrepancies in diagnosis of incident HIV infection between antibody- and DNA-based tests in a phase III prevention trial in southern Africa

Dried blood spots (DBS) are widely used to test for HIV in a variety of research and service delivery settings; however, uniform guidelines regarding collection, storage and DNA extraction processes have neither been developed nor evaluated. Previously published reports suggested DBS may be stored at room temperature for up to 60 days, and intensive stability tests have shown that DBS can withstand high temperatures, humidity and freeze–thawing. During the implementation of a large randomized controlled trial (RCT) in southern Africa, with HIV acquisition as the primary endpoint, we observed 65 instances when DBS samples collected from the same day as a positive HIV antibody test yielded negative DNA polymerase chain reaction (PCR) results. The source of this discrepancy may have been due to inadequate specimen volume, filter paper or DNA extraction procedures, but were most likely due to storage conditions that have been reported as acceptable in other settings.

Curative embolization of brain arteriovenous malformations with onyx: patient selection, embolization technique, and results

BACKGROUND AND PURPOSE

A new curative embolization technique with Onyx for selected small and medium-sized superficially located brain AVMs was developed, which consists of obliteration of the nidus, including incremental occlusion of the draining veins. We report our first clinical results.

MATERIALS AND METHODS

Between June 2008 and July 2011, 24 patients (7 women, 17 men; mean age, 41 years; range, 6-74 years) with AVMs were selected for curative embolization with Onyx. Presentation was hemorrhage in 14 and seizures in 10 patients. AVM location was frontal in 11, occipital in 6, parietal in 4, and temporal in 3. AVM size was a mean of 2.2 cm (median, 2; range, 1-3 cm).

RESULTS

Complete angiographic obliteration of the AVM with Onyx in a single session was achieved in all 24 patients. There were no hemorrhagic or ischemic complications (0%; 95% CI, 0%-16.3%), and no new deficits induced by the treatment. Of 14 patients with ruptured AVMs, 1 patient who presented with a large frontal hematoma died shortly after surgical evacuation of the hematoma following complete embolization of a micro-AVM. Follow-up angiography at 3 months in 23 patients demonstrated a small AVM remnant in 1 that was treated with gamma knife radiosurgery. The other 22 AVMs remained completely occluded.

CONCLUSIONS

In selected patients with small and medium-sized superficial brain AVMs, as defined in our study, injection of Onyx by using a curative embolization technique in a single session seems to provide a safe and effective alternative to radiosurgery or surgery.

Endovascular treatment of ruptured brain AVMs in the acute phase of hemorrhage

BACKGROUND AND PURPOSE

Patients with ruptured brain AVMs are at considerable risk of repeat hemorrhage, particularly when associated intranidal or flow-related aneurysms are present. There is controversy about the timing of diagnosis and treatment of patients with hemorrhagic stroke. We present our results of endovascular treatment of ruptured AVMs in the acute phase.

MATERIALS AND METHODS

Between January 2008 and March 2011, 23 patients (16 men, 7 women; mean age 42 years) with AVM-related hemorrhagic stroke were treated with endovascular techniques within 10 days of the ictus. There were 10 micro-AVMs (< 1 cm) and 1 single-hole pial fistula. In 9 patients, an intranidal or flow-related aneurysm was the likely cause of hemorrhage.

RESULTS

Complete obliteration of the AVM with Onyx was achieved in 13 of 23 patients (57%). Eight of the 13 AVMs were micro-AVMs and 3 had an intranidal aneurysm. Partial obliteration of the AVM was achieved in 10 of 23 patients (43%). In 6 of these 10 patients, an intranidal (n = 1) or flow-related aneurysm (n = 5) was obliterated with Onyx or coils. There were no complications of treatment. During a mean follow-up of 21 months in 22 surviving patients, no repeat hemorrhage occurred.

CONCLUSIONS

Endovascular treatment with Onyx in the acute phase cured most ruptured AVMs. All 9 AVM-associated aneurysms that were considered the source of hemorrhage could be excluded from the circulation. In patients with AVM-related hemorrhagic stroke, prompt angiographic diagnosis and treatment may improve prognosis by reducing repeat hemorrhage rate.

Effect of blind passage and multiple sampling on recovery of Chlamydia trachomatis from urogenital specimens

Detection of chlamydial infections depends on the sensitivity of the techniques used. Variables include the number of body sites sampled, the number of samples obtained, and the number of passages in tissue culture. To assess these factors, microdilution plate cultures with a single blind passage were performed on specimens from 10,291 men and women attending a sexually transmitted disease clinic. Overall, 21% of the men and 30% of the women were culture positive. However, 18% of endocervical, 28% of female urethral, and 29% of male urethral cultures that were positive became so only after a single passage. Of culture-positive women, 23% were positive at the urethra only. Pooled urethral and endocervical specimens were positive more often than an endocervical specimen alone but less often than separately cultured endocervical and urethral specimens. A total of 221 specimens from 92 men and 66 women were subjected to five serial blind passages. Of 83 positive specimens, 29 (35%) were positive only after two or more passages. A total of 37 (46%) women were culture-positive, but only 12 (33%) of those who were positive and had an endocervical culture would have been detected by a single endocervical culture that was not passaged. The sensitivity of chlamydial culture is substantially less than 100% but can be improved by culturing samples from both the urethra and endocervix in women and by serial passage in tissue culture.