Society for Simulation in Healthcare Guidelines for Simulation Training

BACKGROUND

Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist.

METHODS

Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

OBJECTIVE

These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare.

RESULTS

Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided.

CONCLUSIONS

The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Who is the real team leader? Comparing leadership performance of the team leader and CPR Coach during simulated cardiac arrest

Purpose

To describe the leadership performance of team leaders and CPR Coaches, and to determine if there is a correlation between leadership scores and CPR performance during management of simulated pediatric cardiac arrest events.

Methods

This is a secondary analysis of data from a prior randomized controlled trial. We observed the performance of both team leaders and CPR coaches during the management of an 18-minute simulated cardiac arrest scenario which was run for 20 resuscitation teams comprised of CPR-certified professionals from four pediatric tertiary care centers. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. Two raters were trained to use the Behavioral Assessment Tool (BAT) to assess leadership performance of the team leader and CPR Coach. BAT scores of team leaders and CPR coaches were compared and linked with objective CPR performance.

Results

There was no significant difference between the BAT scores of team leaders and CPR coaches (median score 27/40 vs 28.8/40, p = 0.16). Higher BAT scores of team leaders were significantly associated with higher percentage of excellent CPR (r = 0.52, p = 0.02), while higher BAT scores of CPR coaches were significantly associated with higher chest compression fraction (r = 0.48, p = 0.03).

Conclusions

Both team leaders and CPR coaches have similarly high leadership performance during the management of simulated cardiac arrest. Leadership behaviors were associated with quality of CPR performance.Clinical Trial Registration: Registration ID: NCT02539238; https://www.clinicaltrials.gov.

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review

CONTEXT

Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted.

OBJECTIVE

To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation.

DATA SOURCES

Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020.

STUDY SELECTION

3200 titles were retrieved in the initial search; 36 ultimately included for review.

DATA EXTRACTION

Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology.

RESULTS

The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child's resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority.

LIMITATIONS

English language only; lack of randomized control trials; quality of the publications.

CONCLUSIONS

Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020140363.

Closing the gap: a call for a common blueprint for remote distance telesimulation

The physical requirements mandated by the COVID-19 pandemic have presented a challenge and an opportunity for simulation educators. Although there were already examples of simulation being delivered at a distance, the pandemic forced this technique into the mainstream. With any new discipline, it is important for the community to agree on vocabulary, methods and reporting guidelines. This editorial is a call to action for the simulation community to start this process so that we can best describe and use this technique.

Risk orientation predicts hypoxic time during difficult airway simulation: a mixed-methods pilot study

Personality factors may explain some of the practice variation observed in medicine. In this pilot study, we used simulation to investigate the relationship between risk orientation and airway management. We hypothesised that higher risk tolerance would predict earlier intervention.

Ten emergency medicine residents from the University of Alberta participated in a standardised difficult airway simulation. There was a constant rate of oxygen desaturation necessitating eventual airway intervention. A debriefing interview and a risk orientation questionnaire followed. Time of hypoxia prior to intervention was the outcome measure. Audio interview transcripts underwent thematic analysis.

Nine participants were included; one did not complete the simulation as instructed. Higher risk tolerance predicted longer hypoxic time prior to intubation (r=0.72, p=0.03). Theme analysis revealed consistent fears regarding patient instability and chances of a failed airway intervention. Patient instability was emphasised more so by those who intervened earlier.

We show that personality characteristics influence resuscitation decision-making at an early stage of training. Trainees may therefore be susceptible to certain types of medical error based on their risk aversion. Implications for resident training, care quality and patient safety are discussed.

An upgraded interferometer-polarimeter system for broadband fluctuation measurements

Measuring high-frequency fluctuations (above tearing mode frequencies) is important for diagnosing instabilities and transport phenomena. The Madison Symmetric Torus interferometer-polarimeter system has been upgraded to utilize improved planar-diode mixer technology. The new mixers reduce phase noise and allow more sensitive measurements of fluctuations at high frequency. Typical polarimeter rms phase noise values of 0.05°-0.07° are obtained with 400 kHz bandwidth. The low phase noise enables the resolution of fluctuations up to 250 kHz for polarimetry and 600 kHz for interferometry. The importance of probe beam alignment for polarimetry is also verified; previously reported tolerances of ≤0.1 mm displacement for equilibrium and tearing mode measurements minimize contamination due to spatial misalignment to within acceptable levels for chords near the magnetic axis.

Novel HSPB1 mutation causes both motor neuronopathy and distal myopathy

Objective:

To identify the cause of isolated distal weakness in a family with both neuropathic and myopathic features on EMG and muscle histology.

Methods:

Case study with exome sequencing in 2 affected individuals, bioinformatic prioritization of genetic variants, and segregation analysis of the likely causal mutation. Functional studies included Western blot analysis of the candidate protein before and after heat shock treatment of primary skin fibroblasts.

Results:

A novel HSPB1 variant (c.387C>G, p.Asp129Glu) segregated with the phenotype and was predicted to alter the conserved α-crystallin domain common to small heat shock proteins. At baseline, there was no difference in HSPB1 protein levels nor its binding partner αB-crystallin. Heat shock treatment increased HSPB1 protein levels in both patient-derived and control fibroblasts, but the associated increase in αB-crystallin expression was greater in patient-derived than control fibroblasts.

Conclusions:

The HSPB1 variant (c.387C>G, p.Asp129Glu) is the likely cause of distal neuromyopathy in this pedigree with pathogenic effects mediated through binding to its partner heat shock protein αB-crystallin. Mutations in HSBP1 classically cause a motor axonopathy, but this family shows that the distal weakness can be both myopathic and neuropathic. The traditional clinical classification of distal weakness into “myopathic” or “neuropathic” forms may be misleading in some instances, and future treatments need to address the pathology in both tissues.

The accuracy of blood pressure measured by arterial line and non-invasive cuff in critically ill children

BACKGROUND

The accuracy of arterial lines (AL) using the flush test or stopcock test has not been described in children, nor has the difference between invasive arterial blood pressure (IABP) versus non-invasive cuff (NIBP) blood pressure.

METHODS

After ethics approval and consent, we performed the flush test and stopcock test on AL (to determine over damping, under damping, and optimal damping), and determined the difference (NIBP-IABP) in systolic, diastolic, and mean blood pressure (ΔSBP, ΔDBP, and ΔMAP). The primary outcome was incidence (95 % CI) of optimally damped AL. Predictors of ΔBP (effect size (95 % CI)) were determined using multiple linear regression.

RESULTS

There were 147 AL tests in 100 enrolled patients with mean age 44.7 (SD 56) months, weight 16.8 (SD 18.3) kg, male 59 %, postoperative-cardiovascular 52 %, peripheral-AL 78 %, inotropes 29 %, vasodilators 15 %, and ventilated 73 %. The flush test performed in 66 patients (45 %) showed optimal damping in 30 (46 %; 95 % CI 34, 57 %), over damping in 25 (38 %) and under damping in 11 patients (17 %). The stopcock test was over-damped in 128/146 patients (88 %), with the same damping as the flush test in 24/64 (38 %). In optimally damped (flush test) AL, ΔSBP, ΔDBP, and ΔMAP were 0.8 (SD 12.2), -5.2 (SD 8.7), and -4.9 (7.6) respectively. A second set of AL tests was done 2 h later on the same day in 62 patients; AL damping often changed (10/28 flush tests) and ΔBPs correlated poorly (r = 0.31-0.55). Predictors (effect size) of ΔDBP were vasodilator infusion (15.6 (2.9 to 28.3); p = 0.016) and optimal damping (-7.2 (-12.2 to 2.2); p = 0.005); and of ΔMAP were vasodilator infusion (10.0 (-0.3 to 20.4); p = 0.057) and optimal damping (-4.0 (-8 to 0.1); p = 0.058). There were no independent predictors of damping category (n = 66 flush tests).

CONCLUSIONS

Optimally damped AL occur in half of critically ill children, and this is not predictable. There is much variability in ∆BP between NIBP and the gold standard IABP, and this varies even in the same patient on the same day, and is not easily predictable. In critically ill children, NIBP may not be accurate enough to guide management, and more attention to ensuring the AL is optimally damped is needed.

Frequency of rare recessive mutations in unexplained late onset cerebellar ataxia

Sporadic late onset cerebellar ataxia is a well-described clinical presentation with a broad differential diagnosis that adult neurologists should be familiar with. However, despite extensive clinical investigations, an acquired cause is identified in only a minority of cases. Thereafter, an underlying genetic basis is often considered, even in those without a family history. Here we apply whole exome sequencing to a cohort of 12 patients with late onset cerebellar ataxia. We show that 33 % of ‘idiopathic’ cases harbor compound heterozygous mutations in known ataxia genes, including genes not included on multi-gene panels, or primarily associated with an ataxic presentation.

A novel de novo STXBP1 mutation is associated with mitochondrial complex I deficiency and late-onset juvenile-onset parkinsonism

Mutations in STXBP1 have recently been identified as a cause of infantile epileptic encephalopathy. The underlying mechanism of the disorder remains unclear and, recently, several case reports have described broad and progressive neurological phenotypes in addition to early-onset epilepsy. Herein, we describe a patient with early-onset epilepsy who subsequently developed a progressive neurological phenotype including parkinsonism in her early teens. A de novo mutation in STXBP1 (c.416C>T, p.(Pro139Leu)) was detected with exome sequencing together with profound impairment of complex I of the mitochondrial respiratory chain on muscle biopsy. These findings implicate a secondary impairment of mitochondrial function in the progressive nature of the disease phenotype.

Electron kinetic effects on interferometry, polarimetry and Thomson scattering measurements in burning plasmas (invited)

At anticipated high electron temperatures in ITER, the effects of electron thermal motion on Thomson scattering (TS), toroidal interferometer/polarimeter (TIP), and poloidal polarimeter (PoPola) diagnostics will be significant and must be accurately treated. The precision of the previous lowest order linear in τ = Te/mec(2) model may be insufficient; we present a more precise model with τ(2)-order corrections to satisfy the high accuracy required for ITER TIP and PoPola diagnostics. The linear model is extended from Maxwellian to a more general class of anisotropic electron distributions that allows us to take into account distortions caused by equilibrium current, ECRH, and RF current drive effects. The classical problem of the degree of polarization of incoherent Thomson scattered radiation is solved analytically exactly without any approximations for the full range of incident polarizations, scattering angles, and electron thermal motion from non-relativistic to ultra-relativistic. The results are discussed in the context of the possible use of the polarization properties of Thomson scattered light as a method of Te measurement relevant to ITER operational scenarios.

Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial

IMPORTANCE

Resuscitation training programs use simulation and debriefing as an educational modality with limited standardization of debriefing format and content. Our study attempted to address this issue by using a debriefing script to standardize debriefings.

OBJECTIVE

To determine whether use of a scripted debriefing by novice instructors and/or simulator physical realism affects knowledge and performance in simulated cardiopulmonary arrests. DESIGN Prospective, randomized, factorial study design.

SETTING

The study was conducted from 2008 to 2011 at 14 Examining Pediatric Resuscitation Education Using Simulation and Scripted Debriefing (EXPRESS) network simulation programs. Interprofessional health care teams participated in 2 simulated cardiopulmonary arrests, before and after debriefing.

PARTICIPANTS

We randomized 97 participants (23 teams) to nonscripted low-realism; 93 participants (22 teams) to scripted low-realism; 103 participants (23 teams) to nonscripted high-realism; and 94 participants (22 teams) to scripted high-realism groups. INTERVENTION Participants were randomized to 1 of 4 arms: permutations of scripted vs nonscripted debriefing and high-realism vs low-realism simulators.

MAIN OUTCOMES AND MEASURES

Percentage difference (0%-100%) in multiple choice question (MCQ) test (individual scores), Behavioral Assessment Tool (BAT) (team leader performance), and the Clinical Performance Tool (CPT) (team performance) scores postintervention vs preintervention comparison (PPC).

RESULTS

There was no significant difference at baseline in nonscripted vs scripted groups for MCQ (P = .87), BAT (P = .99), and CPT (P = .95) scores. Scripted debriefing showed greater improvement in knowledge (mean [95% CI] MCQ-PPC, 5.3% [4.1%-6.5%] vs 3.6% [2.3%-4.7%]; P = .04) and team leader behavioral performance (median [interquartile range (IQR)] BAT-PPC, 16% [7.4%-28.5%] vs 8% [0.2%-31.6%]; P = .03). Their improvement in clinical performance during simulated cardiopulmonary arrests was not significantly different (median [IQR] CPT-PPC, 7.9% [4.8%-15.1%] vs 6.7% [2.8%-12.7%], P = .18). Level of physical realism of the simulator had no independent effect on these outcomes.

CONCLUSIONS AND RELEVANCE

The use of a standardized script by novice instructors to facilitate team debriefings improves acquisition of knowledge and team leader behavioral performance during subsequent simulated cardiopulmonary arrests. Implementation of debriefing scripts in resuscitation courses may help to improve learning outcomes and standardize delivery of debriefing, particularly for novice instructors.

Nutrition and public health: division of labour in the study of nutrition

This article draws inferences from changes in the style of a nutrition journal which was originally published by the Commonwealth Department of Health, and is now published by the Australian Dietitians' Association. The changes reflect developments in the field of nutrition, towards more 'scientific' styles of inquiry and publishing, against the backdrop of a division of labour in which (mainly male) laboratory scientists produced scientific knowledge which was then communicated by (mainly female) dietitians and nutritionists. Consistent with the approach of the 'new public health', this paper argues that reliance upon 'scientific' methods alone diverts attention from the social, economic and political conditions which help explain not only the improvements earlier in the century, but current difficulties in bringing about further improvements.

A 10-month-old infant with reversible findings of brain death

Death has occurred when there is irreversible loss of integration of the organism as a whole, and brain death is said to be a criterion for death. In the present case, a 10-month-old boy was found submerged in a bathtub and was given cardiopulmonary resuscitation for 37 minutes. He had received therapeutic dosing of phenobarbital and midazolam up to 5 hours prior to a brain death examination. He fulfilled all criteria for brain death according to Canadian Neurological Determination of Death Forum recommendations on an examination 42 hours after the drowning event, but started breathing another 15 hours later. Eleven previously published cases of purported reversal of findings of brain death are discussed here, including two infants who fulfilled all criteria for brain death for more than 24 hours. Recommendations for brain death determination may require revision for infants, to more clearly define a time interval between examinations and to incorporate consideration of confounding sedative drug effects. Together with previous reports, the present case calls into question the assumption that brain death as currently diagnosed is irreversible, and therefore equivalent to death of the patient.

Simulation in paediatrics: An educational revolution

Recent changes in the culture of medical education have highlighted deficiencies in the traditional apprenticeship model of education, and emphasized the need for more experiential modalities of learning. Simulations, which are scenarios or environments designed to closely approximate real-world situations, have recently found their way into the medical training of health care providers. High-fidelity simulators are life-like mannequins connected to computer systems that control the physiological and physical responses of the mannequin. These simulators are able to provide direct feedback to learners in safe, risk-free environments. This technology has been used to teach all aspects of medical care, including medical knowledge, technical skills, and behavioural training or communication skills. The present article provides a general overview of simulation that will hopefully help to generate interest in paediatric simulation across Canada. Several tertiary care paediatric hospitals in Canada are already using simulation to teach health care providers; continued growth and interest is expected in this exciting area of medical education.

Structural dynamics of the human androgen receptor: implications for prostate cancer and neurodegenerative disease

The AR (androgen receptor) is a ligand-activated transcription factor that mediates the action of the steroids testosterone and dihydrotestosterone. Alterations in the AR gene result in a number of clinical disorders, including: androgen-insensitivity, which leads to disruption of male development; prostate cancer; and a neuromuscular degenerative condition termed spinal bulbar muscular atrophy or Kennedy's disease. The AR gene is X-linked and the protein is coded for by eight exons, giving rise to a C-terminal LBD (ligand-binding domain; exons 4-8), linked by a hinge region (exon 4) to a Zn-finger DBD (DNA-binding domain; exons 2 and 3) and a large structurally distinct NTD (N-terminal domain; exon 1). Identification and characterization of mutations found in prostate cancer and Kennedy's disease patients have revealed the importance of structural dynamics in the mechanisms of action of receptors. Recent results from our laboratory studying genetic changes in the LBD and the structurally flexible NTD will be discussed.

[Surgical indications in spinal trauma]

Surgical indications in spinal trauma remain a controversial topic. In general, unstable cervical injuries such as displaced odontoid fractures, burst fractures or tear drop fractures require surgical intervention. Thoracolumbar compression injuries without posterior wall involvement or significant kyphosis can be treated conservatively. Surgery is indicated in fractures-dislocations and burst fractures with significant canal narrowing and/or major kyphosis. The role of emergency decompression as well as that of steroids remain uncertain since no study to date has convincingly proven their efficacy.

Coping effectiveness training reduces depression and anxiety following traumatic spinal cord injuries

OBJECTIVE

To extend the findings of a pilot study that evaluated a brief group-based psychological intervention aimed at improving psychological adjustment, self-perception and enhancing adaptive coping following spinal cord injury. The theoretical underpinnings of the Coping Effectiveness Training (CET) Programme are Lazarus and Folkman's (1984) cognitive theory of stress and coping, and cognitive behavioural therapy techniques.

DESIGN

A controlled trial comparing patients that received the CET intervention with matched controls on measures of psychological adjustment and coping.

METHOD

A total of 45 intervention group participants and 40 matched controls were selected from inpatients at a hospital-based spinal cord injury centre. Outcome measures of anxiety and depression, self-perception and coping were collected before, immediately after and 6 weeks following the intervention.

RESULTS

Intervention group participants showed a significant reduction in depression and anxiety, compared to the matched controls following the intervention. There was no evidence of a significant change in the pattern of coping strategies used by the intervention group compared to controls. The intervention group alone completed measures of self-perception. There was a significant decrease in the discrepancy between participants' 'ideal' self and 'as I am', and between 'as I would be without the injury' and 'as I am' following the intervention and at follow-up. Significant correlations were also found between self-perception, and anxiety and depression over time.

CONCLUSIONS

These results confirm the findings of the pilot study, that the CET intervention facilitated a significant improvement in psychological adjustment to spinal cord injury. It is proposed that this improvement may be understood in terms of changing participants' negative appraisals of the implications of spinal cord injury with the result of increasing the perceived manageability of its consequences. Such decatastrophizing alters appraisals which are associated with current mood. Participants found shared discussion and problem-solving to be particularly helpful. Avenues for further research are discussed.

Phenocopies in a large GCH1 mutation positive family with dopa responsive dystonia: confusing the picture?

BACKGROUND

Dopa responsive dystonia (DRD) is a disorder characterised by childhood onset dystonia but a wide range of clinical presentations has now been described.

OBJECTIVE

To study a large Canadian family with presumed DRD.

METHODS

The clinical features of the family were collected before molecular genetic mutational analysis.

RESULTS

All nine individuals in whom a clinical diagnosis of DRD was definite or probable were heterozygous for a GCH1 gene deletion. However, eight of nine possibly clinically affected members did not carry the GCH1 mutation.

CONCLUSIONS

Great care must be taken in diagnosing DRD even in families with the classic phenotype, because of potential phenocopies of the disease.

Surface enhanced resonance Raman scattering imaging of Langmuir-Blodgett monolayers of bis (benzimidazo) thioperylene

The synthesis, spectroscopic characterization and surface-enhanced spectroscopy of a new electro active organic material bis (benzimidazo) thioperylene (Monothio BZP) are reported. Langmuir monolayers of Monothio BZP were successfully formed on water subphase and characterized by the pi-A surface-pressure area isotherm. Langmuir-Blodgett (LB) monomolecular layers of Monothio BZP were fabricated onto glass substrates and onto silver island films for surface-enhanced spectroscopic studies. The results of surface-enhanced resonance Raman scattering (SERRS), SERRS imaging and surface-enhanced fluorescence (SEF) studies for Monothio BZP LB monolayers are reported. Raman imaging (global imaging and point-by-point mapping) of the SERRS signal for a single monomolecular layer on silver islands were obtained using the 514.5 nm laser line. The SERRS imaging permits a visualization of the variation of the SERRS intensity across of the rough metal surface. The SEF was recorded for the excimer emission of aggregates in the LB film. The distance dependence and the enhancement factor of SEF were determined using fatty acid spacing layers. A temperature dependence study of the LB monolayer SERRS and SEF spectra was carried out between -190 degrees and + 200 degrees C confirming the thermal stability of the LB monolayer on silver. The specificity and the sensitivity of SERRS signal on metal island films was probed using mixed LB films with 0.01% molecular ratio of Monothio BZP in Arachidic Acid (AA). The micro-Raman SERRS spectra from ca. 10(-3) attomole of the dye were recorded.

Asymptomatic intracranial hypertension in disorders of CSF circulation in childhood--treated and untreated

Twelve patients are described who were found to have asymptomatic intracranial hypertension monitored over an extended (6 months to 6 years) period. There were three groups: 5 patients with treated hydrocephalus with an apparently functioning shunt, 4 patients with untreated hydrocephalus, clinically and radiologically nonprogressive, and 3 patients with pseudotumor cerebri, 2 treated and 1 untreated. Although the magnitude of the intracranial pressure changes varied, all patients had abnormal baseline pressures together with repeated A and B waves. In no case was there any clinical manifestation of raised intracranial pressure and in all cases ventricular size remained constant over the period of evaluation. The clinical and pathophysiological implications of these findings are discussed.

Post traumatic stress disorder and spinal cord injuries

Post Traumatic Stress Disorder (PTSD) was first recognised by psychiatric international classification systems in 1980 and a wealth of research and treatment literature has developed since. This paper provides a review of PTSD and Spinal Cord Injuries. A brief history of the disorder is provided before descriptions of the defining characteristics, assessment and differential diagnoses. The paper provides an overview of the incidence and prevalence of PTSD and risk factors within the general population, before considering both veteran and non-veteran research within spinal cord injuries. Pharmacological and psychological approaches to the treatment of PTSD are also discussed. The review closes with recommendations for future research into the prevalence and treatment of PTSD in spinal cord injuries.

Long-term follow-up of unilateral pallidotomy in advanced Parkinson's disease

BACKGROUND

Although the short-term benefits of posteroventral pallidotomy for patients with advanced Parkinson's disease have been well documented, little is known about the long-term outcome of the procedure.

METHODS

We conducted a long-term follow-up study of a cohort of 40 patients who had undergone unilateral posteroventral medial pallidotomy between 1993 and 1996. Twenty patients were not evaluated because they had undergone a second surgical procedure (11 patients) or had died (2) or because they had dementia or another debilitating illness (4), lived too far away (1), or had been lost to follow-up (2). We conducted serial postoperative assessments of parkinsonism in the remaining 20 patients while they were taking medications ("on" period) and after overnight withdrawal of the drugs ("off" period). The mean follow-up time was 52 months (range, 41 to 64).

RESULTS

The combined off-period score for activities of daily living and motor function on the Unified Parkinson's Disease Rating Scale was 18.0 percent better at the last evaluation than at base line (95 percent confidence interval, 4.9 to 31.0 percent; P=0.01). Significant improvements were also evident in the off-period scores for contralateral tremor (65.4 percent improvement, P=0.007), rigidity (43.2 percent, P=0.03), and bradykinesia (18.2 percent, P=0.04) and in the on-period score for contralateral dyskinesia (70.6 percent, P<0.001). Changes in medication did not contribute to the sustained improvement. The 20 patients who could not be included in the long-term analysis had similar base-line characteristics but a worse response to surgery at six months.

CONCLUSIONS

In the group of patients with advanced Parkinson's disease who could be enrolled in our long-term follow-up study of unilateral posteroventral medial pallidotomy (20 patients from the original cohort of 40), significant early improvements in off-period contralateral signs of parkinsonism were sustained for up to five and a half years. There was a sustained significant improvement in on-period contralateral dyskinesia but not in other on-period signs of parkinsonism.

Obesity in leukemia survivors: the familial contribution

A high prevalence of obesity in survivors of acute lymphoblastic leukemia (ALL) has been described, but genetic and social influence in obesity has not been analyzed in this group of patients. The authors studied a population of 33 long-term (25 females, 8 males) in first remission who had reached their final height. All patients received cranial irradiation as part of their central nervous system (CNS)-directed therapy and no patient received growth hormone. The body mass index (BMI: weight/height2) of patients and their biological parents was calculated and submitted to statistical analysis. Obesity was defined as BMI greater than the 85th centile. No excessive obesity was found among the males at final height. Fifty-six percent of the females were obese. In this group of 14 obese female survivors 59% had obese mother, but only 14% had obese fathers. The results indicate a significant maternal predisposition to obesity.

Long-term outcomes for surgically resected craniopharyngiomas

OBJECTIVE

This retrospective study critically analyzed the long-term functional outcomes and tumor recurrence rates for surgically treated craniopharyngiomas.

METHODS

This study used an outcome classification system that included functioning vision, independent versus dependent living, Karnofsky Performance Scale scores, academic levels, work status, and psychological status. Tumor recurrence rates were analyzed with respect to the extent of surgical resection and adjunctive radiotherapy.

RESULTS

For 121 patients, with a mean follow-up period of 10 years, the overall "good outcome" rate was 60.3%. Factors associated with poor outcomes included lethargy at presentation, visual deterioration, papilledema, tumor calcification, hydrocephalus, and tumor adhesiveness at surgery. Gross total resection was associated with good outcomes (P = 0.017) and decreased risk of recurrence (P = 0.024). Subtotal resection was associated with increased risk of tumor recurrence (P = 0.0235). The highest risk of recurrence was in the subtotal resection/no radiation group (P = 0.0001). There were no differences in outcomes or recurrence rates between pediatric and adult patients. There were also no differences in outcomes or recurrence rates between papillary and adamantinous tumors. Approximately one-third of patients exhibited morbid obesity, and permanent diabetes insipidus was observed for 25 patients.

CONCLUSION

A rigorous evaluation of outcomes for tumors such as craniopharyngiomas must consider not only the extent of resection, as judged by postoperative imaging, but also the long-term physical, intellectual, and psychological functioning of the patients.

Posteroventral medial pallidotomy in Parkinson's disease

There has been a resurgence in the use of functional neurosurgery for Parkinson's disease. An important factor that has played a role in this development is the recent understanding of the functional anatomy of the basal ganglia including a knowledge of the changes in the activities of neurons in the internal segment of the globus pallidus (Gpi) and the subthalamic nucleus (STN) in Parkinson's disease as well as the knowledge of the presence of segregated functional loops within the basal ganglia which include a sensory-motor loop that involves the posteromedial globus pallidus rather than the anterior GPi where earlier pallidotomy lesions had been made. Laitinen reintroduced the modern posteroventral medial pallidotomy (PVMP) in 1992. Since then it has become clear that this treatment has major effects on levodopa-induced dyskinesias and, unlike Vim thalamotomy, improves bradykinesia and rigidity as well as tremor. In this report, we review a number of topics related to PVMP including the clinical results of pallidotomy available in the literature as well as an update of our own 2 year follow-up data, studies evaluating factors that might predict the subsequent response to pallidotomy, the neuropsychological effects of the procedure, results of imaging studies including the correlation of clinical effects with lesion location, the question of bilateral pallidotomy and pallidotomy combined with deep brain stimulation and finally whether PVMP is effective in other parkinsonian disorders.

Relationship of lesion location to clinical outcome following microelectrode-guided pallidotomy for Parkinson's disease

The purpose of this study was to examine the relationship between lesion location and clinical outcome following globus pallidus internus (GPi) pallidotomy for advanced Parkinson's disease. Thirty-three patients were prospectively studied with extensive neurological examinations before and at 6 and 12 months following microelectrode-guided pallidotomy. Lesion location was characterized using volumetric MRI. The position of lesions within the posteroventral region of the GPi was measured, from anteromedial to posterolateral along an axis parallel to the internal capsule. To relate lesion position to clinical outcome, hierarchical multiple regression analysis was used. The variance in outcome measures that was related to preoperative scores and lesion volume was first calculated, and then the remaining variance attributable to lesion location was determined. Lesion location along the anteromedial-to-posterolateral axis within the GPi influenced the variance in total score on the Unified Parkinson's Disease Rating Scale in the postoperative 'off' period, and in 'on' period dyskinesia scores. Within the posteroventral GPi, anteromedial lesions were associated with greater improvement in 'off' period contralateral rigidity and 'on' period dyskinesia, whereas more centrally located lesions correlated with better postoperative scores of contralateral akinesia and postural instability/gait disturbance. Improvement in contralateral tremor was weakly related to lesion location, being greater with posterolateral lesions. We conclude that improvement in specific motor signs in Parkinson's disease following pallidotomy is related to lesion position within the posteroventral GPi. These findings are consistent with the known segregated but parallel organization of specific motor circuits in the basal ganglia, and may explain the variability in clinical outcome after pallidotomy and therefore have important therapeutic implications.