Prolactin, a hormone synthesized by the anterior pituitary gland demonstrates promise as a neuroprotective agent, however, its role in humans and in vivo during injury is not fully understood.
To ...investigate whether elevated levels of prolactin attenuate injury to the retinal nerve fiber layer (RNFL) following compression of the optic chiasm in patients with a prolactin secreting pituitary macroadenoma (i.e., prolactinoma).
A retrospective cross-sectional study of all pituitary macroadenoma patients treated at a single institution between 2009 and 2019.
Primary outcome measures included RNFL thickness, mean deviation, and prolactin levels for both prolactin-secreting and non-secreting pituitary macroadenoma patients.
Sixty-six patients met inclusion criteria for this study (14 prolactin-secreting and 52 non-secreting macroadenoma patients). Of 52 non-secreting macroadenoma patients, 12 had moderate elevation of prolactin secondary to stalk effect. Patients with moderate elevation in prolactin demonstrated increased RNFL thickness compared to patients with normal prolactin levels (p < 0.01). Additionally, a significant positive relation between increasing levels of prolactin and RNFL thickness was identified in patients with moderate prolactin elevation (R = 0.51, p-value = 0.035). No significant difference was identified between prolactinoma patients and those with normal prolactin levels.
Moderately increased serum prolactin is associated with increased RNFL thickness when compared to controls. These associations are lost when serum prolactin is < 30 ng/ml or elevated in prolactinomas. This suggests a neuroprotective effect of prolactin at moderately increased levels in preserving retinal function during optic chiasm compression.
Lumbosacral facet dislocations are rare lesions typically seen in high-energy trauma. This type of injury is a severe flexion-distraction injury and is extremely rare, with only six other documented ...reports. A recent case series proposed a classification for lumbosacral injuries which would classify the present case as a 1C, meaning a bilateral dislocation with anterior slippage of the L5 vertebra without fractures of the articulating processes (AP), pars interarticularis (PI), or vertebral bodies (VB). In this case report, we discuss the third case of a class 1C injury in a pediatric patient, review the associated literature and discuss the presentation, diagnosis, management, and prognosis of these rare dislocations.
Abstract
Objective
Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in ...patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation.
Data sources
PubMed was queried for publications with the Medical Subject Headings (MeSH) terms “mechanical ventilation” and “aneurysmal subarachnoid hemorrhage” published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest.
Study selection
Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies.
Data extraction
Articles were reviewed by one team member, and interpretation was verified by a second team member.
Data synthesis
Thirty-one articles met the inclusion criteria for this review.
Conclusions
We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.
Abstract Background context There is a persistent trend for more outpatient lumbar discectomies in the United States. Purpose To investigate the characteristics of the patients selected for ...ambulatory procedures. Study design Retrospective cohort study. Patient sample Forty-seven thousand one hundred twenty-five patients who underwent outpatient and 102,592 patients undergoing inpatient lumbar discectomies and were were registered in the State Ambulatory Surgery Database (SASD) and State Inpatient Database (SID), respectively, for New York, California, Florida, and North Carolina from 2005 to 2008. Outcome measures Rate of outpatient procedures, 30-day readmissions, and hospital charges. Methods We performed a retrospective cohort study involving patients who underwent outpatient and inpatient lumbar discectomies and were registered in SASD and SID, respectively, for New York, California, Florida, and North Carolina from 2005 to 2008. Logistic regression models were used to demonstrate the association of socioeconomic factors with the odds of undergoing an outpatient procedure. Results Male gender (odds ratio OR, 1.05; 95% confidence interval CI, 1.03–1.08), private insurance (OR, 1.93; 95% CI, 1.86–2.01), lower Charlson Comorbidity Index (OR, 4.04; 95% CI, 3.17–5.16), and higher volume hospitals (OR, 1.06; 95% CI, 1.04–1.08) were significantly associated with outpatient procedures. Higher income (OR, 0.83; 95% CI, 0.81–0.85), older age (OR, 0.996; 95% CI, 0.995–0.997), coverage by Medicaid (OR, 0.89; 95% CI, 0.83–0.96), African Americans (OR, 0.65; 95% CI, 0.60–0.70), and other minority races were associated with decreased odds of outpatient procedures. The rate of 30-day postoperative readmissions was higher among inpatients. Institutional charges were significantly lower for outpatient lumbar discectomies. The median charge for inpatient surgery was $24,273 as compared with $11,339 for the outpatient setting (p<.0001). Conclusions Access to ambulatory lumbar discectomies appears to be more common for younger, white, male patients, with private insurance and less comorbidities, in the setting of higher volume hospitals. Further investigation is needed in the direction of mapping these disparities for appropriate resource utilization.
Persistent pain after lumbar surgery (failed back surgery syndrome FBSS) remains a leading indication for chronic analgesia. However, no analgesics have proven efficacious for this condition. ...Although trials have evaluated gabapentinoids for chronic low back pain, none of these trials focused solely on FBSS. This randomized, double-blind cross-over trial evaluated the efficacy of gabapentin (1800 mg/day) for FBSS. Eligible patients had a diagnosis of FBBS, an average daily pain score of at least 4 of 10, a neuropathic pain component (indicated by the PainDetect), and reported at least half of their pain radiating in their lower extremity. Participants were randomized to 2, 7-week study periods separated by a 10-day washout. The primary outcome measure was a 0 to 10 numeric rating scale (NRS) of average pain. Secondary measures included the McGill Pain Questionnaire and Patient Global Impression of Change. The treatment effect was analyzed using a mixed effect analysis of covariance with fixed effects for treatment, period, and baseline 7-day mean NRS pain score and a random effect for the participant. The outcome of the model was the mean 7-day NRS score for the last 7 days of each treatment period. Thirty-two participants were randomized and included in the primary analysis; 25 completed both study periods. No difference was detected between treatments on any outcome measure, including the primary (least square mean difference in NRS: -0.01 confidence interval: -0.22 to 0.20). Given the escalating rate of complex lumbar surgery, future research to develop novel therapies for this prevalent syndrome is needed.
Background
Outcomes for octogenarians and nonagenarians after an aneurysmal subarachnoid hemorrhage (aSAH) are particularly ominous, with mortality rates well above 50%. The present analysis examines ...the neurologic outcomes of patients ≥ 80 years of age treated for aSAH.
Method
A retrospective review was performed of all aSAH patients treated at Barrow Neurological Institute from January 1, 2003, to July 31, 2019. Patients were placed in 2 groups by age, < 80 vs ≥ 80 years. The ≥ 80-year-old group of octogenarians and nonagenarians was subsequently analyzed to compare treatment modalities. Poor neurologic outcome was defined as a modified Rankin Scale (mRS) score of > 2.
Results
During the study period, 1418 patients were treated for aSAH. The mean (standard deviation) age was 55.1 (13.6) years, the mean follow-up was 24.6 (40.0) months, and the rate of functional independence (mRS 0–2) at follow-up was 54% (751/1395). Logistic regression analysis found increasing age strongly associated with declining functional independence (
R
2
= 0.929,
p
< 0.001). Forty-three patients ≥ 80 years old were significantly more likely to be managed endovascularly than with open microsurgery (67%
n
= 29 vs 33%
n
= 14,
p
< 0.001). Compared with younger patients, those ≥ 80 years old had an increased risk of mortality and poor neurologic outcomes at follow-up. In the ≥ 80-year-old group, only 4 patients had good outcomes; none of the 4 had preexisting comorbidities, and all 4 were treated endovascularly.
Conclusions
Age is a significant prognostic indicator of functional outcomes and mortality after aSAH. Most octogenarians and nonagenarians with aSAH will become severely disabled or die.
Randomized trials have demonstrated a survival benefit for endovascular treatment of ruptured cerebral aneurysms. We investigated the association of surgical clipping and endovascular coiling with ...outcomes in subarachnoid hemorrhage (SAH) patients in a real-world regional cohort.
We performed a cohort study involving patients with ruptured cerebral aneurysms, who underwent surgical clipping, or endovascular coiling from 2009-2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. An instrumental variable analysis was used to investigate the association of treatment technique with outcomes.
Of the 4,098 patients undergoing treatment, 2,585 (63.1%) underwent coiling, and 1,513 (36.9%) underwent clipping. Using an instrumental variable analysis, we did not identify a difference in inpatient mortality marginal effect (ME), -0.56; 95% CI, -1.03 to 0.02, length of stay (LOS) (ME, 1.72; 95% CI, -3.39 to 6.84), or the rate of 30-day readmissions (ME, -0.30; 95% CI, -0.82 to 0.22) between the two treatment techniques for patients with SAH. Clipping was associated with a higher rate of discharge to rehabilitation (ME, 0.63; 95% CI, 0.24 to 1.01). In sensitivity analysis, mixed effect regression, and propensity score adjusted regression models demonstrated identical results.
Using a comprehensive all-payer cohort of patients in New York State presenting with aneurysmal SAH we did not identify an association of treatment method with mortality, LOS or 30-day readmission. Clipping was associated with a higher rate of discharge to rehabilitation.
Proliferative Angiopathy: A Systematic Review Brown, Nolan J.; Lien, Brian V.; Ehresman, Jeff ...
Stroke: vascular and interventional neurology,
05/2024, Letnik:
4, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Background First described over 4 decades ago as a diffuse form of arteriovenous malformation, cerebral proliferative angiopathy (CPA) is now categorized as a distinct vascular anomaly. Unlike ...arteriovenous malformation, which typically forms a well‐developed vascular nidus with feeder vessels and distinct venous outflow, CPA is the product of disorganized angiogenesis; thus, it lacks a true nidus. Its characteristic cycle of ischemia, angiogenesis, and aberrant perfusion can lead to abnormal blood flow patterns that characterize the disease. Treatment of CPA has historically relied on conservative management (antiepileptic drugs), and efforts to effectively manage this pathology have been hindered by an incomplete understanding of its natural history. Methods A systematic search of 4 databases was performed. The following variables were extracted when present: study sample size, year of publication, age(s) of patient(s), sex, presenting signs and symptoms, neurological deficits (pre‐ and postoperative), type of intervention, average follow‐up time, and patient‐reported as well as functional outcomes at last follow‐up. Results Following the search and screen, 48 studies reporting 105 CPA cases remained eligible for inclusion. These studies consisted of 41 case reports, 6 case series, and 1 retrospective cohort study. The most common modality used in treatment of CPA was conservative management (53.4%). The second most common treatment modality was endovascular embolization (36.9%). The least common treatment modality was gamma knife radiosurgery, which was used in only 2 patients. Eleven patients experienced intracranial hemorrhage as a complication of CPA; 10 of the 11 patients underwent decompressive craniectomy. Finally, revascularization surgery was reportedly used in 5 patients (4.9%). Conclusion Although there remains a dearth of studies reporting CPA, several clearly defined traits have been identified that characterize this pathology and distinguish it from arteriovenous malformation. Nonetheless, the verdict has not yet been reached regarding the effectiveness of surgical interventions.
To perform a systematic review and meta-analysis evaluating the efficacy of middle meningeal artery embolization in terms of both clinical and radiographic outcomes, when performed with different ...embolic agents.
A systematic literature review and meta-analysis was performed to evaluate the impact of embolic agents on outcomes for middle meningeal artery (MMA) embolization. The use of polyvinyl alcohol (PVA) with or without (±) coils, N-butyl cyanoacrylate (n-BCA) ± coils, and Onyx alone were separately evaluated. Primary outcome measures were recurrence, the need for surgical rescue and in-hospital periprocedural complications.
Thirty-one studies were identified with a total of 1,134 patients, with 786 receiving PVA, 167 receiving n-BCA, and 181 patients receiving Onyx. There was no difference in the recurrence rate (5.5% for PVA, 4.5% for n-BCA, and 6.5% for Onyx, with P=0.71) or need for surgical rescue (5.0% for PVA, 4.0% for n-BCA, and 6.9% for Onyx, with P=0.89) based on the embolic agent. Procedural complications also did not differ between embolic agents (1.8% for PVA, 3.6% for n-BCA, and 1.6% for Onyx, with P=0.48).
Rates of recurrence, need for surgical rescue, and periprocedural complication following MMA embolization are not impacted by the type of embolic agent utilized. Ongoing clinical trials may be used to further investigate these findings.
The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a ...meta-analysis of the current literature on MSU performance.
Our MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours ("per day"), mechanical thrombectomy (MT)/dispatch and MT/day.
Our MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150-0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074-0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8-9.5%, I
= 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215-0.502, I
= 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2-2.8%, I
= 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046-0.138, I
= 91%).
In this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.
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