The Diagnostic Value of Abnormal Bone Marrow Signal Changes on Magnetic Resonance Imaging: Is Bone Marrow Biopsy Essential?

BACKGROUND

It is essential to determine whether bone marrow signal changes on magnetic resonance imaging (MRI) represent a physiological response or pathology; at present, the clinical significance of these signal changes is unclear. It is unknown whether a bone marrow biopsy is required when bone marrow signal changes are detected incidentally in individuals without suspected malignancy.

OBJECTIVE

The primary purpose of this study was to determine whether incidentally detected bone marrow signal changes on MRI performed for various reasons (at the time of admission or during follow-up) are clinically significant.

METHODS

We retrospectively evaluated the bone marrow biopsy clinical and laboratory findings of 42 patients with incidental bone marrow signal changes on MRI between September 2016 and January 2020. We also determined whether the patients were diagnosed with malignancy during admission or follow-up.

RESULTS

Of the 42 patients, three (7%) were diagnosed with hematological malignancies during admission, while two were diagnosed with multiple myeloma and one with B-cell acute lymphoblastic leukemia. Of the 42 patients, 35 had a mean follow-up of 40.6 ± 5.3 months. One patient was diagnosed with monoclonal gammopathy of undetermined significance four months after their first admission.

CONCLUSIONS

In addition to MRI, detailed clinical and laboratory evaluations should be performed to inform the decision for bone marrow biopsy and exclude hematological malignancy. If there is any doubt, a bone marrow biopsy should be performed. Moreover, since bone marrow signal changes may be a preliminary finding, follow-up of these patients is essential.

A Prospective Study of Nurse-Led Oral Mucositis Management: Impact on Health Outcomes of Patients Receiving Radiotherapy for Head and Neck Cancer and Lung Cancer

OBJECTIVES

The study aimed to evaluate the impact of nurse-led mucositis management on the health outcomes of patients receiving radiotherapy for head and neck cancer and lung cancer. The study adopted a holistic approach that involved the patient in the care process by screening, providing education and counseling about mucositis management and integrating it into daily life by the radiotherapy nurse.

DATA SOURCES

In this prospective, longitudinal cohort study, 27 patients were assessed and monitored through use of the WHO Oral Toxicity Scale and Oral Mucositis Follow-up Form and educated on mucositis during their radiotherapy through use of the Mucositis Prevention and Care Guide. At the end of radiotherapy, an evaluation of the radiotherapy process was performed. In this study, each patient was followed for 6 weeks from the start of radiotherapy.

CONCLUSION

The worst clinical data for oral mucositis and its variables emerged at week 6 of treatment. While the Nutrition Risk Screening score increased over time, weight decreased was observed to decrease. The mean stress level was 4.74 ± 0.33 in the first week and 5.77 ± 0.35 in the last week. It was observed that 88.9% of the patients showed good compliance with the treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nurse-led mucositis management contributes to better patient outcomes during the radiotherapy process. Such an approach improves oral care management in patients receiving radiotherapy for head and neck and lung cancer, demonstrating its positive impact on additional patient-focused outcomes.

The effect of food intake during hemodialysis on blood pressure: A nonrandomized experimental trial

BACKGROUND

Intradialytic hypotension (IDH) is one of the most important intradialytic complications and is thought to be associated with intradialytic food intake. Allowing intradialytic feeding is still unclear. This study aimed to determine the relationship between IDH and intradialytic food intake.

METHODS

A nonrandomized experimental study was conducted to determine the effect of intradialytic food intake on blood pressure (BP) in hemodialysis patients. Each patient was assessed twice using an ambulatory BP monitor with and without intradialytic food intake.

RESULTS

The study was completed with 54 patients. Intradialytic hypotension developed in 40 patients (74.1%) during the food intake session, while intradialytic hypotension developed in 22 participants (40%) in the no-food session. Repeated BP readings showed that eating 2 h or more after the start of hemodialysis significantly reduced BP.

CONCLUSIONS

Intradialytic food intake affects the development of IDH. Patients who ate during hemodialysis had a trend of higher of IDH than those who ate nothing during hemodialysis. Eating during dialysis is not recommended.

Development and evaluation of the efficacy of a web-based education program among cancer patients undergoing treatment with systemic chemotherapy: a randomized controlled trial

Purpose

The study aimed to develop a web-based education program among cancer patients undergoing treatment with systemic chemotherapy and to evaluate the efficacy of the program on symptom control, quality of life, self-efficacy, and depression.

Methods

A web-based education program was prepared in line with patient needs, evidence-based guidelines, and expert opinions and tested with 10 cancer patients. The single-blind, randomized controlled study was conducted at a medical oncology unit of a university hospital. Pretests were applied to 60 cancer patients undergoing treatment with systemic chemotherapy, and the patients (intervention: 30, control: 30) were randomized. The intervention group used a web-based education program for 3 months, and they were allowed to communicate with researchers 24/7 via the website. The efficacy of a web-based education program at baseline and after 12 weeks was evaluated. The CONSORT 2010 guideline was performed.

Results

In the first phase results of the study, it was found that most of the patients with cancer wanted to receive education about symptom management and the side effects of the treatment. Expert opinions on the developed website were found to be compatible with each other (Kendall’s Wa = 0.233, p = 0.008). According to the randomized controlled study results, patients who received web-based education reported significantly fewer symptoms (p = 0.026) and better quality of life (p = 0.001), but there was no statistically significant difference in the self-efficacy and depression levels during the 3-month follow-up period (p˃0.05). The most frequently visited links in the web-based education program by the patients with cancer were the management of chemotherapy-related symptoms (62.6%).

Conclusion

A web-based education program was found to be efficacy in remote symptom management and improving the quality of life of cancer patients.

Trial registration

www.clinicaltrials.gov, NCT05076916 (October 12, 2021, retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07039-w.

Real-life ruxolitinib experience in intermediate-risk myelofibrosis

Background

In this retrospective cohort of patients with primary, post-polycythemia vera, or post-essential thrombocythemia myelofibrosis, 57 patients with MF who received ruxolitinib for MF-related symptoms or symptomatic splenomegaly were evaluated.

Methods

The median age of the patients in this cohort was approximately 58 years. Of these, there were 33 patients (57.9%) in INT-1, 23 patients (40.4%) in INT-2, and 1 patient (1.8%) at high risk. Overall, spleen size reduction of at least 35% (spleen response) was achieved in 56.6% and 63.3% of all cohort and INT-1 risk at any time, respectively.

Results

Symptom response and clinical improvement were observed in 21.7% and 60.7% of patients, respectively. Anemia and thrombocytopenia were prevalent, but manageable. About 73.7% of patients continued treatment during a median follow-up of 22 months. Two-year OS probability was approximately 84.5% (95% CI, 63.1‒94.0%) and 62.3% (95% CI, 37.5‒79.6%) for the intermediate-1 and -2 risk groups, respectively.

Conclusion

Real-life experience in a community-based hospital confirms the efficacy and safety profile of ruxolitinib in intermediate-risk myelofibrosis. Treatment discontinuation rates were lower than those in clinical trials.

Barriers to Adoption of Electronic Health Record Systems from the Perspective of Nurses: A Cross-sectional Study

This study report aimed to investigate the barriers to implementation of electronic health record systems from the perspective of nurses. The research data comprised responses from nurses working in a university hospital. Our data collection instruments were the Participant Information Form and EHR Nurse Opinion Questionnaire, which were developed by the researchers. Data analysis was presented as summary statistics, including mean values of variables, standard deviation, frequency, and percentages. A total of 160 nurses participated in the study. The mean age of participants was 30.94 ± 0.59 years, and 77.5% were university graduates. Barriers to adoption of the electronic health record system included high number of patients (82.8%), limited time (79%), lack of knowledge and skills for effective use of the system (22.9%), lack of user-friendly interface and inability to create a common language within the team (17.8%), and attachment to the traditional method (17.2%). Although most nurses thought that the electronic health record system offered some advantages, they reported that factors such as large numbers of patients, limited time, and lack of user-friendly interface hindered its adoption. Innovative strategies should be explored to develop user-friendly designs for electronic health records and to produce solutions for nursing shortages to increase the time allocated for patient care.

Hiccups in Cancer Patients Receiving Chemotherapy: A Cross-Sectional Study

CONTEXT

Hiccups are a symptom in cancer patients but it's less researched.

OBJECTIVES

The aimed to determine of prevalence of hiccups and treatment approach used in hiccup management in cancer patients receiving chemotherapy for nursing care.

METHODS

This study used a descriptive cross-sectional design with self-reported questionnaires and was conducted from November 2018-May 2019 in Turkey. For collection of the data, a Patient Information Form (sociodemographic and disease characteristics), and a Hiccups Evaluation Form were used for the patients.

RESULTS

Hiccups were observed in 37 (23%) of the 160 patients who met the criteria for inclusion in the study. The great majority of the patients suffering from hiccups were male (65.9%) and the type of cancer in the majority of these patients was gastrointestinal cancer (54.1%). It was determined that the duration of hiccups in 83.8% of patients observed with hiccups was between 0 and 48 hours, that the average severity of their hiccups was 3.81 ± 2.25 (0-10), and that hiccups in 59.5% of these patients was of low severity. It was found that only 10.8% of patients suffering from hiccups used pharmacological methods for relief and that 27% used nonpharmacological methods.

CONCLUSION

The results of the study showed that over one-fifth of cancer patients suffered from hiccups. This situation reveals that hiccups are an important symptom that needs to be carefully emphasised in oncology practice.

Student Nurse Knowledge of and Attitudes Toward Pressure Injury Prevention: How Sufficient Is Undergraduate Education?

OBJECTIVES

To assess the knowledge and attitudes of student nurses regarding evidence-based guidelines for preventing pressure injuries.

METHODS

This study used a descriptive research design. The participants included second-, third-, and fourth-year nursing students completing their bachelor's degrees at a faculty of nursing in Turkey. Data collection forms consisted of a student nurse information form, the Pressure Ulcer Prevention Knowledge Assessment Instrument, and the Attitude Towards Pressure Ulcer Prevention Instrument.

RESULTS

The overall mean score for knowledge was 49.9% (11.7/26). The highest scores for the instrument's subthemes were for nutrition (72%), and the lowest were for etiology and development (40.1%). The overall mean attitude score was 42.20 ± 2.40, although a statistically significant difference among grades was found (P < .001). The highest mean scores showed agreement among students that pressure injury prevention should be a priority (10.50 ± 1.43). A significant difference was found in the competence subscale according to the number of dressing changes observed and sense of competence in pressure injury care (P = .003). A weak but statistically significant positive relationship was found between knowledge and attitude scores (r = 0.158; 95% confidence interval, .040-.269; P < .001).

CONCLUSIONS

This study revealed that certain revisions are needed in the nursing curriculum to improve the knowledge and attitudes of nursing students toward the prevention and care of pressure injuries. More details should be covered in the classroom and laboratories through simulation or clinical practice for improved management of pressure injuries.

Being an international nursing student in Turkey: A qualitative study

PURPOSE

The purpose of this study is to explore the perspectives of international nursing students in Turkey on their learning experience.

DESIGN AND METHODS

Qualitative semi-structured individual interviews and focus group interviews were used to explore nursing students' perspectives on their learning experiences in Turkey. The research population comprised 10 international students.

RESULTS

The students expressed fear of being rejected by patients in a clinical setting, as well as feelings of isolation and discrimination. They feel foreign and experience the typical prejudice against their color and language.

PRACTICE IMPLICATIONS

Educators should take language and cultural differences into consideration and should listen to international students regarding education methods. Teachers of international students, both academic and clinical, need to be cognizant of the "otherness" of international students.

Quality of Life and Symptom Burden With First- and Second-generation Tyrosine Kinase Inhibitors in Patients With Chronic-phase Chronic Myeloid Leukemia

BACKGROUND

With the advent of tyrosine kinase inhibitors (TKIs), patients with chronic myeloid leukemia (CML) have a life expectancy similar to those of age- and gender-matched healthy populations. Nevertheless, patients receiving TKIs report chronic adverse events such as fatigue, edema, and muscle cramps, which lead to a decrease in their quality of life (QoL). Therefore, the aim of this study was to assess the QoL and symptom burden in patients receiving original imatinib, generic imatinib, dasatinib, and nilotinib.

PATIENTS AND METHODS

A total of 121 patients with CML who received TKIs for at least 3 months were enrolled in the study. The QoL was assessed with the Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) and Quality of Life Questionnaire-Chronic Myeloid Leukemia (QLQ-CML24) modules. The symptom burden was assessed with MD Anderson Symptom Inventory for Chronic Myeloid Leukemia (MDASI-CML) and EORTC QLQ-CML24.

RESULTS

The median age of the study population was 53 years (range, 28-90 years), and 83 (81.4%) patients had a low-to-medium Sokal risk score. The Eastern Cooperative Oncology Group performance status of most patients were good (< 2; 96%), and comorbidity scores were low (HCT-CI < 3; 90.8%). There was no significant difference between the general health status of patients in terms of EORTC QLQ-C30 and QLQ-CML24. According to the results of the MDASI-CML and QLQ-CML24 modules, the most common symptom was fatigue (58.7%) in all groups, and there were no significant differences between the groups in terms of the effects on the daily life activities of the patients.

CONCLUSION

Patients with CML receiving first- and second-generation TKIs were seen to have a similar QoL and symptom burden.

Correction to: Fertility in testicular cancer patients: a single‑centre study in Turkey

The updated version of Table 4 of original publication and the Compliance with ethical standards are given in this correction.

Psychometric validation of the Turkish version of the Supportive Care Needs Survey for Partners and Caregivers (SCNS-P&C-T) of cancer patients

OBJECTIVE

To evaluate the validity and reliability study of the Supportive Care Needs Survey for partners and caregivers of cancer patients in Turkish society (SCNS-P&C-T).

METHODS

This cross-sectional survey followed by a test-retest reliability and psychometric validation study was conducted with 270 participants. The research data were collected using a patient and caregiver demographic survey, the SCNS-P&C-T, the Caregiver Strain Index, and the Hospital Anxiety and Depression Scale.

RESULTS

Ten expert opinions were found to be consistent for content validity of the scale (I-CVI = 0.993, S-CVI = 0.956). The confirmatory factor analysis could not confirm the factor structure of the original scale. Therefore, an exploratory factor analysis was performed and the scale factor structure was determined. These factor structures are (a) psychological and emotional needs, (b) health care and information, (c) work and social needs, (d) communication and family needs.

CONCLUSION

The SCNS-P&C-T is a valid and reliable tool which can be used to identify unmet needs among caregivers in Turkish populations.

Acromegaly remission, SIADH and pituitary function recovery after macroadenoma apoplexy

Summary

Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome characterised by ischaemic infarction or haemorrhage into a pituitary tumour that can lead to spontaneous remission of hormonal hypersecretion. We report the case of a 50-year-old man who attended the emergency department for sudden onset of headache. A computed tomography (CT) scan at admission revealed pituitary haemorrhage and the blood test confirmed the clinical suspicion of acromegaly and an associated hypopituitarism. The T1-weighted magnetic resonance imaging (MRI) showed the classic pituitary ring sign on the right side of the pituitary. Following admission, he developed acute-onset hyponatraemia that required hypertonic saline administration, improving progressively. Surprisingly, during the follow-up, IGF1 levels became normal and he progressively recovered pituitary function.

Learning Points

Patients with pituitary apoplexy may have spontaneous remission of hormonal hypersecretion. If it is not an emergency, we should delay a decision to undertake surgery following apoplexy and re-evaluate hormone secretion. Hyponatraemia is an acute sign of hypocortisolism in pituitary apoplexy. However, SIADH although uncommon, could appear later as a consequence of direct hypothalamic insult and requires active and individualised treatment. For this reason, closely monitoring sodium at the beginning of the episode and throughout the first week is advisable to guard against SIADH. Despite being less frequent, if pituitary apoplexy is limited to the tumour, the patient can recover pituitary function previously damaged by the undiagnosed macroadenoma.

[Causes of hospital mortality due to brain haemorrhage in patients with arteriovenous malformation]

AIM

To determine the causes of mortality in cases of brain haemorrhage among patients with arteriovenous malformations (AVM) treated in a tertiary hospital.

PATIENTS AND METHODS

The patients with AVM who died over the period 1990-2014 were selected from a prospective register of vascular malformations. Demographic aspects, localisation of the AVM, associated aneurysms and previous treatments were reviewed. Three main causes of death were established: initial bleeding/rebleeding, those related with the treatment of the AVM and other causes not related with AVM.

RESULTS

A total of 400 patients were treated for AVM, 216 (54%) with a ruptured AVM, of whom 26 (12.1%) died as a result of a brain haemorrhage. The mean age of the group of patients who died was 48.8 years (range: 8-78 years). Twenty (76.9%) were admitted in coma (Glasgow Coma Scale < 9). In five cases (19.2%), bleeding was due to an associated aneurysm. A very high percentage (38.5%) had the AVM in the posterior fossa. Three patients had previously received non-curative treatments for the AVM in other medical centres. Of the total number, six (23.1%) received endovascular/surgical treatment in our hospital, and we have assumed that, due to the indication or owing to the time in which it was carried out, the cause of death was treatment-related, although two young patients underwent surgery with bilateral mydriasis. One patient died due to an associated glioblastoma, and the others, 19 (76%), due to rebleeding or to the initial brain damage.

CONCLUSION

Knowing the causes of mortality can help improve the clinical outcome, above all in cases in which an early treatment could be indicated.

Cultural sensitivity levels of university students receiving education in health disciplines

Medical and nursing students are expected to be more competent in terms of being acquainted with different cultures and approaching culturally, compared to many other disciplines. This descriptive study was designed to evaluate the cultural sensitivity levels of nursing and medical students and the affecting factors. One hundred and eleven nursing and 164 medical students were included in the study. The data were collected by using a questionnaire questioning the variables that were thought to affect the cultural sensitivity of students and the intercultural sensitivity scale. According to results of the study; it was observed that university students receiving education in the fields of medicine and nursing had good cultural sensitivity levels and those interacting with people from other cultures and speaking a foreign language had significantly higher cultural sensitivity levels (p < 0.05). According to these results, it was thought that it would be useful to develop plannings aimed at increasing the language proficiency in university curriculums and abroad experience opportunities of students, and to design qualitative studies based on interviews and observations aimed at examining the factors affecting the intercultural sensitivity.

[Aneurysmal subarachnoid hemorrhage: group of study of cerebrovascular pathology of the Spanish society of neurosurgery management guideline]

An actualized revision of the most important aspects of aneurismal subarachnoid hemorrhage is presented from the guidelines previously published by the group of study of cerebrovascular pathology of the Spanish Society of Neurosurgery. The proposed recommendations should be considered as a general guide for the management of this pathological condition. However, they can be modified, even in a significant manner according to the circumstances relating each clinical case and the variations in the therapeutic and diagnostic procedures available in the center attending each patient.

[Primary decompressive craniectomy in patients with aneurysmatic subarachnoid hemorrhage. Results of a pilot study in 11 cases]

INTRODUCTION

Despite the scientific and technical advances of recent years, aneurysmal subarachnoid hemorrhage (aSAH) continues to present a high morbidity and mortality. This fact, together with the impressive results of the primary decompressive craniotomy (PDC) in the malignant infarction of the middle cerebral artery suggests a possible beneficial effect of decompressive technique in aSAH. We present our experience of a pilot study that PDC was used in patients with poorgrade aSAH with associated intracerebral hematoma.

PATIENTS AND METHODS

Between March 1st, 2002 and 31st April, 2008, 342 patients with aneurysmatic subarachnoid hemorrhage (aSAH) were treated at our hospital. Of these, 64 had a poor neurological grade (scores of 4 or 5 of the World Federation of Neurosurgical Societies) at the time of admission. The present study examines 11 of those patients who underwent PDC, which is performed in the same clipping and / or evacuation of an associated hematoma.

RESULTS

In three patients PDC was performed after endovascular aneurysm treatment because of the need to evacuate an associated hematoma. In the eight remaining patients, PDC was performed in the same clipping and evacuation of the associated hematoma. Outcome evaluation of these eleven patients was conducted 1 year after the operation assessed by the Glasgow Outcome Scale. Six patients survived, and four of them with good results. The PDC was effective in controlling intracranial pressure in all six surviving patients. However, two of these six patients had unfavorable outcomes. Of the five who didn't survive, one patient died from a delayed epidural-subgaleal hematoma as a complication of the decompressive technique, and the other four patients died because of refractory intracranial hypertension.

CONCLUSIONS

Primary DC may be beneficial in selected subgroups of patients with poor-grade aSAH. However, there is a lack of definitive evidence to support a clear recommendation for its use.

[Spontaneous Subarachnoid Haemorrhage multicenter database from the Group for the Study of Vascular Pathology of the Spanish Society for Neurosurgery: presentation, inclusion criteria and development of an internet-based registry]

INTRODUCTION

Subarachnoid haemorrhage is one of the most severe neurosurgical diseases. Its study is crucial for improving the care of these patients in our environment. With this goal the Group for the Study of Neurovascular Pathology of the Spanish Society for Neurosurgery (SENEC) decided to create a multicenter registry for the study of this disease.

MATERIALS AND METHODS

In this database we have prospectively included all cases with spontaneous subarachnoid haemorrhage admitted to the participant hospitals from November 2004 to November 2007. The fields to be included in the database were selected by consensus, including age, past medical history, clinical characteristics at admission, radiological characteristics including presence or absence of an aneurysm and its size and location, type and complications of the aneurysm treatment, outcome assessed by the Glasgow Outcome Scale (GOS) at discharge and six months after the bleeding as well as the angiographic result of the aneurysm treatment. All fields were collected by means of an electronic form posted in secure web page.

RESULTS

During the three years of study a total of 1149 patients have been included by 14 Hospitals. The time needed to fill in a patient in the registry is approximately 3.4 minutes. This series of patients with spontaneous SAH is similar to other non-selected in-hospital series of SAH. The mean age of the patients is 55 years and there is a 4:3 female to male ratio. In relation to the severity of the bleeding 32% of the patients were in poor clinical grade at admission (WFNS 4 or 5). 5% of the patients died before angiography could be performed. An aneurysm was confirmed as the origin of the bleeding in 76% of the patients (aSAH), while in 19% of the patients no lesion was found in the angiographic studies and were thus classified as idiopathic subarachnoid hemorrhage (ISAH). Of those patients with aSAH, 47% were treated endovascularly, 39% surgically, 3% received a combined treatment and 11% did not receive any treatment for their aneurysm because of early death. Regarding outcome, there is a 22% mortality in the series. Only 40% of the patients with aSAH reached a good outcome at discharge (GOS = 5).

CONCLUSIONS

Spontaneous SAH continues to be a disease with high morbidity and mortality. This database can be an ideal instrument for improving the knowledge about this disease in our environment and to achieve better results. It would be desirable that this database could in the future be the origin of a national registry of spontaneous SAH.

[Detection of episodes of ischemic tissue hypoxia by means of the combined intraoperative neurophysiologic monitoring with the tissue oxygenation monitoring in aneurysm surgery]

INTRODUCTION

Intraoperative neuromonitoring in aneurysm surgery can be very useful to determine inadequate positions of the vascular clip that cause partial or complete compromise of the cerebral sanguineous flow in the vascular territories irrigated by the arteries related to aneurysm. The direct visualization of these arteries after the application of the surgical clip can be insufficient in detecting this potentially detrimental situation. Knowing this circumstance on the onset would allow the neurosurgeon to correct it and to avoid, therefore, cerebral ischemic tissue hypoxia. We show the utility of the intraoperative monitoring of the oxygen tissue pressure (PtiO2) and the somatosensorial evoked potential (SSEP) for the detection of these situations with the example of a clinical case.

CLINICAL CASE

We present the case of a 62 year-old woman, that presented with subarachnoid hemorrhage of aneurysmal origin. The cerebral arteriography demonstrated the existence of an aneurysm of the posterior communicating artery that was treated initially by endovascular procedure with partial exclusion of the aneurysm. For this reason it was decided to complete the treatment with a programmed surgery. The patient was put on an intraoperative monitoring system with a PtiO2 sensor located in the risk area and with SSEP. After positioning the surgical clip the partial oxygen pressure decreased rapidly, as well as the amplitude of the cortical potential of the left posterior tibial nerve. The knowledge of this situation allowed the detection of a trapped posterior communicating artery. After correcting this situation by replacing the surgical clip, both variables recovered to their basal values.

CONCLUSIONS

The intraoperative PtiO2 monitoring, combined with neurophysiologic monitoring during aneurysm surgery offers a fast and trustworthy form of early detection of ischemic phenomena caused by bad positioning of the surgical clip.

Replantation of a vertically fractured maxillary central incisor after repair with adhesive resin

AIM

To describe the replantation of a vertically fractured root-filled maxillary central incisor after repair with adhesive resin.

SUMMARY

Root-filled teeth with vertical root fractures are usually extracted as they generally have a poor prognosis. In this case, an 18-month follow-up of a replanted incisor with vertical root fracture is presented with clinical and radiographic documentation.

KEY LEARNING POINTS

* Replantation of root-filled incisors with complete vertical root fracture after resin bonding might be a realistic alternative to extraction. * Practitioners should be aware of the possible disadvantages as well as advantages associated with failure of a replanted incisor with complete vertical root fracture.

Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury

BACKGROUND

High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). High ICP is treated by general maneuvers (normothermia, sedation etc) and a set of first line therapeutic measures (moderate hypocapnia, mannitol etc). When these measures fail to control high ICP, second line therapies are started. Among these, second line therapies such as barbiturates, hyperventilation, moderate hypothermia or removal of a variable amount of skull bone (known as decompressive craniectomy) are used.

OBJECTIVES

To assess the effects of secondary decompressive craniectomy (DC) on outcome and quality of life in patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP.

SEARCH STRATEGY

We searched the Cochrane Injuries Group's Trial Register, CENTRAL, MEDLINE, EMBASE, Best Evidence, Clinical Practice Guidelines, PubMed, CINAHL, the National Research Register and Google Scholar. We also handsearched relevant conference proceedings and contacted experts in the field and the authors of included studies.

SELECTION CRITERIA

Randomized or quasi-randomized studies assessing patients over the age of 12 months with a severe TBI who underwent DC to control ICP refractory to conventional medical treatments.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the electronic search results for reports of possibly relevant trials and for retrieval in full. One author applied the selection criteria, performed the data extraction and assessed methodological quality. Study authors were contacted for additional information.

MAIN RESULTS

We found one trial with 27 participants conducted in the pediatric population (>18 years). DC was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72), and RR of 0.54 for death, vegetative status or severe disability 6 to 12 months after injury (95% CI 0.29 to 1.07).

AUTHORS' CONCLUSIONS

There is no evidence to support the routine use of secondary DC to reduce unfavourable outcome in adults with severe TBI and refractory high ICP. In the pediatric population DC reduces the risk of death and unfavourable outcome. Despite the wide confidence intervals for death and the small sample size of the only study identified, this treatment maybe justified in patients below the age of 18 when maximal medical treatment has failed to control ICP. To date, there are no results from randomised trials to confirm or refute the effectiveness of DC in adults. However, the results of non-randomized trials and controlled trials with historical controls involving adults, suggest that DC may be a useful option when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of DC (Rescue ICP and DECRAN) that may allow further conclusions on the efficacy of this procedure in adults.

[Variability in the surgical indications for posttraumatic intradural lesions]

INTRODUCTION

The surgical treatment of focal intradural lesions is still a matter of considerable debate. This is especially important in the decision to evacuate brain contusions. We present the results of a prospective observational study in which the main goal was to analyze intracenter variability in the indication for surgery in focal posttraumatic intradural lesions in a department of Neurosurgery of a University Hospital with a specialized neurotrauma unit.

CLINICAL MATERIAL AND METHODS

Between May 1 and December 31, 2001, 32 patients with a closed traumatic brain injury and an intradural posttraumatic focal lesion were included. The patients studied were a subgroup included in the European multicenter observational study of the management of intradural lesions conducted under the aegis of the European Brain Injury Consortium (EBIC).

RESULTS

Intradural lesions > 25 cc were immediately evacuated. Nine out of thirteen patients with lesions < 25 cc also underwent surgery due to intracranial hypertension or neuroworsening. In all patients in whom lesions were surgically evacuated, the postoperative CT-scan showed neuroradiological improvement of the signs of mass effect or midline shift.

CONCLUSIONS

In our center, we found no evidence of significant variability in the indications for surgery in intradural lesions of more than 25 cc. However, significant differences were detected among neurosurgeons in the surgical indications for lesions below 25 cc. The small sample analyzed precludes generalization of these conclusions. The definitive results of the EBIC study will provide the neurosurgical community with a better understanding of variability in the management of these lesions.

[Use of teleradiology in the evaluation and management of head-injured patients. Results of a pilot study of a link between a district general hospital and a neurosurgical referral center]

Because of the centralization of neurosurgical services, many head-injured patients who are initially evaluated in district general hospitals need to be transferred to a high technology centre for neurosurgical assessment. However, after assessment, many of these patients are sent back to the original hospital. Establishing a teleradiological system between the two hospitals would eliminate these unnecessary transfers.

OBJECTIVES

1) to describe our initial experience and the results of a pilot study of the teleradiological link between a district general hospital and a tertiary hospital for neurosurgical assessment of head-injured patients, 2) to describe the infrastructure and the technological support required for this project, 3) to analyse the effects of the teleradiological link in both centers (referring and receiving), 4) to evaluate the effectiveness of the system in avoiding unnecessary transfers, and 5) to assess its effectiveness in improving the speed and the quality of transfers in head-injured patients.

MATERIAL AND METHODS

In January 1998, the Neurotraumatology Unit of Vall d'Hebron University Hospital established a teleradiological link with the General Hospital of Vic for the neurosurgical evaluation of headinjured patients. The General Hospital of Vic sent the patients' clinical information by fax. CT scan images were digitalized, compressed and prepared for transmission with the StatView program, and were then transmitted by modem to the receiving center. The duty neurosurgeon viewed the images on a PC screen using MutiView software. After evaluating this clinical and radiological information the neurosurgeon sent a report back to the referring center recommending transfer or management (admission, observation, etc.).

RESULTS

We analyse the results of our experience 5 years after the implantation of the teleradiological link.

CONCLUSIONS

The use of teleradiology in the daily management of head-injured patients provides clear benefits and leads to a more rational use of resources, thus significantly reduces costs. The effectiveness of the system in reducing the interval between the injury and treatment in severe cases depends more on the infrastructure of the health system in each geographical area than on sophisticated telemedicine systems. These methods should be accompanied by other measures designed to hasten the transfer of selected patients.

Intracranial hypertension after surgery in patients with Chiari I malformation and normal or moderate increase in ventricular size

OBJECTIVE

To determine ICP changes in patients with Chiari type I malformation after posterior fossa reconstruction (PFR).

PATIENTS AND METHODS

We continuously monitored ICP before and after PFR in 12 patients with Chiari I malformation and with an Evans' Index below or equal to 0.33. Mean ICP (epidural sensor) and percentage of B waves were calculated 24 hours before surgery and during the first 7 days after surgery.

RESULTS

Mean ICP and percentage of B waves significantly increased after surgery despite a significant increase in the volume of the posterior fossa. The main finding revealed by control CT scans was compression of the quadrigeminal cistern with a reduction in size of the fourth ventricle. In six patients, a small transitory increase in supratentorial ventricular size was found.

CONCLUSIONS

A transitory increase in ICP is common after PFR. This increase could be explained by an initial reperfusion phenomena in the cerebellum that provokes a transitory deterioration in CSF dynamics. The effacement of the quadrigeminal cistern and the reduction in size of the fourth ventricle suggests this hypothesis.

[Arteriovenous malformations of the posterior fossa. Clinical features, treatment and results]

OBJECTIVES

We present our experience of 20 cases of arteriovenous malformations (MAV) of the posterior fossa.

PATIENTS AND METHODS

During the period 1991 1999 we prospectively collected radiological and therapeutic clinical data and the results obtained in all cases of adults whose arterio venous malformations were treated. We selected 20 of those who had MAV of the posterior fossa.

RESULTS

The average age was 39.6 years (15 64). Thirteen (65%) were men. Most patients, 16 cases (80%) presented clinically with cerebellar haemorrhage, subarachnoid and/or intraventricular haemorrhage and 6 (30%) of the patients were admitted in coma. On the Spetzler and Martin scale: grade 1, 1 patient (5%); grade 11, 8 patients (40%); grade 111, 8 patients (40%) and grade 1V, 3 patients (15%). One patient had an associated pedicular aneurysm, another a supratentorial MAV and another patient had several cavernomas. Nine patients required external ventricular drainage, which in 4 cases became a permanent CSF drainage system. Endovascular treatment was used in 8 patients, radiosurgery in 2 and surgery in 9. Complete resection of the MAV was only possible in the patients treated by surgery (two patients had been treated previously by embolizations and radiosurgery). In this series there was a mortality of 20%, in all four cases due to recurrence of bleeding. Good results were obtained in 11 (55%) of the patients, but in the other 5 (25%) there were sequelas.

CONCLUSION

The high percentage with haemorrhages as the form of presentation, with a much higher mortality than that of supratentorial MAVs makes more aggressive treatment necessary.