Deep brain stimulation of different targets has been shown to drastically improve symptoms of a variety of neurological conditions. However, the occurrence of disabling side effects may limit the ...ability to deliver adequate amounts of current necessary to reach the maximal benefit. Computed models have suggested that reduction in electrode size and the ability to provide directional stimulation could increase the efficacy of such therapies. This has never been demonstrated in humans. In the present study, we assess the effect of directional stimulation compared to omnidirectional stimulation. Three different directions of stimulation as well as omnidirectional stimulation were tested intraoperatively in the subthalamic nucleus of 11 patients with Parkinson's disease and in the nucleus ventralis intermedius of two other subjects with essential tremor. At the trajectory chosen for implantation of the definitive electrode, we assessed the current threshold window between positive and side effects, defined as the therapeutic window. A computed finite element model was used to compare the volume of tissue activated when one directional electrode was stimulated, or in case of omnidirectional stimulation. All but one patient showed a benefit of directional stimulation compared to omnidirectional. A best direction of stimulation was observed in all the patients. The therapeutic window in the best direction was wider than the second best direction (P = 0.003) and wider than the third best direction (P = 0.002). Compared to omnidirectional direction, the therapeutic window in the best direction was 41.3% wider (P = 0.037). The current threshold producing meaningful therapeutic effect in the best direction was 0.67 mA (0.3-1.0 mA) and was 43% lower than in omnidirectional stimulation (P = 0.002). No complication as a result of insertion of the directional electrode or during testing was encountered. The computed model revealed a volume of tissue activated of 10.5 mm(3) in omnidirectional mode, compared with 4.2 mm(3) when only one electrode was used. Directional deep brain stimulation with a reduced electrode size applied intraoperatively in the subthalamic nucleus as well as in the nucleus ventralis intermedius of the thalamus significantly widened the therapeutic window and lowered the current needed for beneficial effects, compared to omnidirectional stimulation. The observed side effects related to direction of stimulation were consistent with the anatomical location of surrounding structures. This new approach opens the door to an improved deep brain stimulation therapy. Chronic implantation is further needed to confirm these findings.
To date, no civilian studies have demonstrated that pre-hospital (PH) tourniquets improve survival. We hypothesized that late, trauma center (TC) tourniquet use would increase death from hemorrhagic ...shock compared to early (PH) placement.
All patients arriving to a Level 1, urban TC between October 2008 and January 2016 with a tourniquet placed before (T-PH) or after arrival to the TC (T-TC) were evaluated. Cases were assigned the following designations: indicated (absolute indication vascular injury requiring repair/ligation, operation within 2 hours for extremity injury, or traumatic amputation or relative indication major musculoskeletal/soft tissue injury requiring operation 2-8 hours after arrival, documented large blood loss) or non-indicated. Outcomes were death from hemorrhagic shock, physiology upon arrival to the TC, and massive transfusion requirements. After univariate analysis, logistic regression was carried out to assess independent predictors of death from hemorrhagic shock.
A total of 306 patients received 326 tourniquets for injuries to 157 upper and 147 lower extremities. Two hundred eighty-one (92%) had an indication for placement. Seventy percent of patients had a blunt mechanism of injury. T-TC patients arrived with a lower systolic blood pressure (SBP, 101 86, 123 vs. 125 100, 145 mm Hg, p < 0.001), received more transfusions in the first hour of arrival (55% vs. 34%, p = 0.02), and had a greater mortality from hemorrhagic shock (14% vs. 3.0%, p = 0.01). When controlling for year of admission, mechanism of injury and shock upon arrival (SBP ≤90 mm Hg or HR ≥120 bpm or base deficit ≤ 4) indicated T-TC had a 4.5-fold increased odds of death compared to T-PH (OR 4.5, 95% CI 1.23-16.4, p = 0.02).
Waiting until TC arrival to control hemorrhage with a tourniquet was associated with worsened blood pressure and increased transfusion within the first hour of arrival. In routine civilian trauma patients, delaying to T-TC was associated with 4.5-fold increased odds of mortality from hemorrhagic shock.
Level IV.
Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control ...adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects.
This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05.
A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%).
Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage.
Therapeutic study, level IV.
In 2013, we implemented a pill-based, multi-modal pain regimen (MMPR) in order to decrease in-hospital opioid exposure after injury at our trauma center. We hypothesized that the MMPR would decrease ...inpatient oral morphine milligram equivalents (MME), decrease opioid prescriptions at discharge, and result in similar Numerical Rating Scale (NRS) pain scores.
Adult patients admitted to a level-1 trauma center with ≥1 rib fracture from 2010 to 2017 were included – spanning 3 years before and 4 years after MMPR implementation. MME were summarized as medians and interquartile range (IQR) by year of admission. The effect of the MMPR on daily total MME was estimated using Bayesian generalized linear model.
Over the 8 year study period, 6,933 patients who met study inclusion criteria were included. No significant differences between years were observed in Abbreviated Injury Scale (AIS) Chest or Injury Severity Scores (ISS). After introduction of the MMPR, there was a significant reduction in median total MME administered per patient day from 60 MME/patient day (IQR 36–91 MME/patient day) pre-MMPR implementation to 37 MME/patient day (IQR 18–61 MME/patient day) in 2017, p < 0.01. Total MME administered per patient day decreased by 31% in 2017 as compared to 2010 (rate ratio 0.69, 95% CI 0.64–0.75). Average NRS pain scores decreased by 0.8 points (95% CI -0.87, −0.81) from 2010 to 2017.
The introduction of a multi-modal pain regimen resulted in significant reduction in in-patient opioid exposure after injury. The reduction in inpatient opioid use from 2010 to 2017 was equivalent to 11 mg less oxycodone or 17 mg less hydrocodone per patient per day. Additionally, use of the MMPR was associated with a reduction in NRS pain scores.
•Implementation of a Multi-Modal Pain Regimen in trauma patients led to decreased opioid use.•Patient pain scores significantly decreased after Multi-Modal Pain Regimen implementation.•No significant differences in adverse events such as ileus, cardiac arrest, or deaths.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background Conventional craniotomy approaches involve substantial soft tissue manipulation that can cause complications. The transciliary supraorbital keyhole approach was developed to avoid ...these complications. Objective To review the safety and effectiveness of the transciliary supraorbital keyhole approach. Material and Methods We searched the PubMed/Medline database for full-text publications from 1996 onward containing data on 100 or more cases of aneurysm clipping or tumor resection by the transciliary supraorbital approach. The primary outcome was the incidence of approach-related complications. The secondary outcomes were the aneurysm occlusion rate and the extent of tumor resection. Results Eight publications met the eligibility criteria. All publications were of the retrospective case-series or case-cohort type without any independent assessment of outcomes. The risk of bias at the individual study level may thus have influenced any conclusions drawn from the overall study population, which included 2783 patients with 3085 lesions (2508 aneurysms and 577 tumors). Approach-related complications included 3.3% CSF collection or CSF leak, 4.3% permanent and 1.6% temporary supraorbital hypesthesia, 2.9% permanent and 1% temporary facial nerve palsy, and 1% wound healing disturbance/infection. Complete aneurysm clipping was achieved in 97% of cases, and complete tumor resection in 90% of cases. The overall surgical revision rate was 2.5%. The esthetic outcome was typically reported as highly acceptable. Conclusions This approach may represent a safe, effective, and less invasive alternative to conventional craniotomy in experienced hands and for a well-selected subset of patients. However, higher-level evidence is needed to confirm this hypothesis.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Abstract
BACKGROUND
The goals of treating Koos grade IV vestibular schwannomas are to relieve brainstem compression, preserve or restore neurological function, and achieve long-term tumor control ...while minimizing tumor- and treatment-related morbidity.
OBJECTIVE
To propose a treatment paradigm involving the intentional near-total removal of Koos grade IV vestibular schwannomas, in which a small amount of residual tumor is not dissected off the cisternal portion of the facial nerve. Patients are then followed by a wait-and-scan approach. Any subsequent volumetric progression of the residual tumor is treated with radiosurgery.
METHODS
This is a case series of 44 consecutive unselected patients who underwent intended near-total resection of a Koos grade IV vestibular schwannoma through a retrosigmoid approach from January 2009 to December 2015. Pre- and postoperative volumetric analyses were performed on routine magnetic resonance imaging sequences (constructive interference in steady state and gadolinium-enhanced T1-weighted sequence).
RESULTS
The mean preoperative tumor volume was 10.9 cm3. The mean extent of resection was 89%. At the last clinical follow-up, facial nerve function was good House and Brackmann (HB) I-II in 89%, fair (HB III) in 9%, and poor (HB IV-VI) in 2% of the patients. At the last radiological follow-up, the residual tumor had become smaller or remained the same size in 84% of patients. Volumetric progression was negatively correlated with the original extent of resection and positively correlated with postoperative residual tumor volume (P = .01, P < .001, respectively).
CONCLUSION
Intended near-total removal results in excellent preservation of facial nerve function and has a low recurrence rate. Any progressive residual tumor may be treated by radiosurgery.
Major venous injury (MVI) affecting the lower extremity can result in subsequent amputation. The contribution of intraoperative resuscitation efforts on the need for amputation is not well defined. ...We hypothesized that intraoperative large volume crystalloid resuscitation (LVCR) increases the risk of amputation after MVI, while massive transfusion (MT) does not.
We performed a retrospective review of patients with infrarenal MVI from 2005 to 2015 at seven urban level I trauma centers. The outcome of interest was the need for secondary amputation.
478 patients were included. 31 (6.5%) patients with MVI required amputation. LVCR(p < 0.001), combined arterial/venous injury (p = 0.001), and associated fracture (p = 0.001) were significant risk factors for amputation. MT did not significantly increase amputation risk (p = 0.44). Multivariable logistic regression model demonstrated that patients receiving ≥5L LVCR(aOR (95% CI): 9.7 (2.9, 33.0); p < 0.001), with combined arterial/venous injury (aOR (95% CI):3.6 (1.5, 8.5); p = 0.004), and with an associated fracture (aOR (95% CI):3.2 (1.5, 7.1); p = 0.004) were more likely to require amputation.
Patients with MVI who receive LVCR, have combined arterial/venous injuries and have associated fractures are more likely to require amputation. MT was not associated with delayed amputation.
•Large volume crystalloid resuscitation increases risk for amputation after major venous injury.•Massive transfusion is not correlated with increased need for amputation.•Combined arterial/venous injury increases risk of amputation.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Deep brain stimulation of the subthalamic nucleus (STN-DBS) ameliorates motor function in patients with Parkinson's disease and allows reducing dopaminergic therapy. Beside effects on motor function ...STN-DBS influences many non-motor symptoms, among which decline of verbal fluency test performance is most consistently reported. The surgical procedure itself is the likely cause of this decline, while the influence of the electrical stimulation is still controversial. STN-DBS also produces widespread changes of cortical activity as visualized by quantitative EEG. The present study aims to link an alteration in verbal fluency performance by electrical stimulation of the STN to alterations in quantitative EEG.
Sixteen patients with STN-DBS were included. All patients had a high density EEG recording (256 channels) while testing verbal fluency in the stimulator on/off situation. The phonemic, semantic, alternating phonemic and semantic fluency was tested (Regensburger Wortflüssigkeits-Test).
On the group level, stimulation of STN did not alter verbal fluency performance. EEG frequency analysis showed an increase of relative alpha2 (10-13 Hz) and beta (13-30 Hz) power in the parieto-occipital region (
≤ 0.01). On the individual level, changes of verbal fluency induced by stimulation of the STN were disparate and correlated inversely with delta power in the left temporal lobe (
< 0.05).
STN stimulation does not alter verbal fluency performance in a systematic way at group level. However, when in individual patients an alteration of verbal fluency performance is produced by electrical stimulation of the STN, it correlates inversely with left temporal delta power.
Background:
Recent studies suggest movements of speech and gait in patients with Parkinson's Disease (PD) are impaired by a common underlying rhythmic dysfunction. If this being the case, motor ...deficits in speech and gait should equally benefit from rhythmic interventions regardless of whether it is a speech-specific or step-training-specific approach.
Objective:
In this intervention trial, we studied the effects of two rhythmic interventions on speech and gait. These rhythmic intervention programs are similar in terms of intensity and frequency (i.e., 3x per week, 45 min-long sessions for 4 weeks in total), but differ regarding therapeutic approach (rhythmic speech vs. rhythmic balance-mobility training).
Methods:
This study is a cross-over, parallel multi-arms, single blind intervention trial, in which PD patients treated with rhythmic speech-language therapy (rSLT;
N
= 16), rhythmic balance-mobility training (rBMT;
N
= 10), or no therapy (NT;
N
= 18) were compared to healthy controls (HC;
N
= 17; matched by age, sex, and education:
p
> 0.82). Velocity and cadence in speech and gait were evaluated at baseline (BL), 4 weeks (4W-T1), and 6 months (6M-T2) and correlated.
Results:
Parameters in speech and gait (i.e., speaking and walking velocity, as well as speech rhythm with gait cadence) were positively correlated across groups (
p
< 0.01). Statistical analyses involved
repeated measures
ANOVA across groups and time, as well as
independent
and
one-samples t-tests
for within groups analyses. Statistical analyses were amplified using
Reliable Change (RC)
and
Reliable Change Indexes (RCI)
to calculate true clinically significant changes due to the treatment on a patient individual level. Rhythmic intervention groups improved across variables and time (total Mean Difference: 3.07 SD 1.8; 95% CI 0.2–11.36) compared to the NT group, whose performance declined significantly at 6 months (
p
< 0.01). HC outperformed rBMT and NT groups across variables and time (
p
< 0.001); the rSLT performed similarly to HC at 4 weeks and 6 months in speech rhythm and respiration.
Conclusions:
Speech and gait deficits in PD may share a common mechanism in the underlying cortical circuits. Further, rSLT was more beneficial to dysrhythmic PD patients than rBMT, likely because of the nature of the rhythmic cue.
BackgroundAlthough widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients ...for whom our surgeons had equipoise and hypothesized that definitive laparotomy (DEF) would reduce major abdominal complications (MAC) or death within 30 days compared with DCL.MethodsEligible patients undergoing emergency laparotomy were randomized during surgery to DCL or DEF from July 2016 to May 2019. The primary outcome was MAC or death within 30 days. Prespecified frequentist and Bayesian analyses were performed.ResultsOf 489 eligible patients, 39 patients were randomized (DCL 18, DEF 21) and included. Groups were similar in demographics and mechanism of injury. The DEF group had a higher Injury Severity Score (DEF median 34 (IQR 20, 43) vs DCL 29 (IQR 22, 41)) and received more prerandomization blood products (DEF median red blood cells 8 units (IQR 6, 11) vs DCL 6 units (IQR 2, 11)). In unadjusted analyses, the DEF group had more MAC or death within 30 days (1.71, 95% CI 0.81 to 3.63, p=0.159) due to more deaths within 30 days (DEF 33% vs DCL 0%, p=0.010). Adjustment for Injury Severity Score and prerandomization blood products reduced the risk ratio for MAC or death within 30 days to 1.54 (95% CI 0.71 to 3.32, p=0.274). The Bayesian probability that DEF increased MAC or death within 30 days was 85% in unadjusted analyses and 66% in adjusted analyses.ConclusionThe findings of our single center pilot trial were inconclusive. Outcomes were not worse with DCL and, in fact, may have been better. A randomized clinical trial of DCL is feasible and a larger, multicenter trial is needed to compare DCL and DEF for patients with severe abdominal trauma.Level of evidenceLevel II.
PDF
