Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience

BACKGROUND

Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes.

OBJECTIVE

To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period.

METHODS

Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose-area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection.

RESULTS

Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease.

CONCLUSIONS

TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA.

Circulating levels of dickkopf-1, osteoprotegerin and sclerostin are higher in old compared with young men and women and positively associated with whole-body bone mineral density in older adults

Bone mineral density declines with increasing older age. We examined the levels of circulating factors known to regulate bone metabolism in healthy young and older adults. The circulating levels of dickkopf-1, osteocalcin, osteoprotegerin and sclerostin were positively associated with whole-body bone mineral density (WBMD) in older adults, despite the average WBMD being lower and circulating dickkopf-1, osteoprotegerin and sclerostin being higher in old than young.

INTRODUCTION

This study aims to investigate the relationship between whole-body bone mineral density (WBMD) and levels of circulating factors with known roles in bone remodelling during 'healthy' ageing.

METHODS

WBMD and fasting plasma concentrations of dickkopf-1, fibroblast growth factor-23, osteocalcin, osteoprotegerin, osteopontin and sclerostin were measured in 272 older subjects (69 to 81 years; 52% female) and 171 younger subjects (18-30 years; 53% female).

RESULTS

WBMD was lower in old than young. Circulating osteocalcin was lower in old compared with young, while dickkopf-1, osteoprotegerin and sclerostin were higher in old compared with young. These circulating factors were each positively associated with WBMD in the older adults and the relationships remained after adjustment for covariates (r values ranging from 0.174 to 0.254, all p < 0.01). In multivariate regression, the body mass index, circulating sclerostin and whole-body lean mass together accounted for 13.8% of the variation with WBMD in the older adults. In young adults, dickkopf-1 and body mass index together accounted for 7.7% of variation in WBMD.

CONCLUSION

Circulating levels of dickkopf-1, osteocalcin, osteoprotegerin and sclerostin are positively associated with WBMD in community-dwelling older adults, despite the average WBMD being lower and circulating dickkopf-1, osteoprotegerin and sclerostin being higher in old than young.

Perceived barriers to participating in continuing education: the views of newly registered community pharmacists

Objective

The main aim of this study was to explore newly registered community pharmacists' attitudes to the current provision of continuing education (CE) and to identify key factors that act as motivators and barriers to participation in CE.

Method

Eight focus groups of newly registered pharmacists were set up. All focus groups were tape-recorded and transcribed verbatim. The results presented in this paper focus specifically on the barriers to participation in CE.

Setting

Four geographical areas of England.

Key findings

The main barrier identified by the pharmacists was competing demands on their time, both in and out of work. Participants felt disillusioned with further study, describing this stage of their lives as a “honeymoon period” in which they sought to make adjustments in both their professional and personal lives. They also felt disillusioned with the reality of community pharmacy and offered this as an explanation for their lack of involvement in CE. In addition, many pharmacists believed themselves to be at the peak of their pharmaceutical knowledge, thus not requiring CE. Rather, it was felt that they needed to develop their skills in other areas such as communication skills or applying pharmaceutical knowledge in practice. It was suggested that this could only be remedied through working with and learning from more experienced pharmacists, rather than undertaking formal CE activities.

Conclusion

Non-participation in CE may be seen to result from a complex web of factors which do not easily map on to policies to increase participation of newly registered pharmacists in CE activities. Nevertheless, if newly registered community pharmacists are to achieve the continuity of learning necessary for continuing professional development, education providers will need to address their specific learning needs in the period following registration.

The effect of orthodontic referral guidelines: a randomised controlled trial

OBJECTIVE

To develop and evaluate the effectiveness of referral guidelines for the referral of orthodontic patients to consultant and specialist practitioner orthodontists.

DESIGN

Single centre randomised controlled trial with random allocation of referral guidelines for orthodontic treatment to general dental practitioners.

SETTING

Hospital orthodontic departments and specialist orthodontic practices in Manchester and Stockport.

SUBJECTS

General dental practitioners and the patients they referred for orthodontic treatment.

MAIN OUTCOME MEASURE

Appropriateness of referral, defined as whether the patient was accepted for orthodontic treatment.

RESULTS

The referral guidelines did not reduce the number of inappropriate referrals.

CONCLUSIONS

Referral guidelines for orthodontic referrals did not influence the behaviour of the general dental practitioners. More research into the optimum methods of dissemination and implementation of referral guidelines for use in the general dental service is needed.

Hemispheric asymmetries in arousal affect outcome of the intracarotid amobarbital test

Objective: To evaluate changes in arousal and their impact on memory performance during the intracarotid amobarbital test (IAT).

Methods: Along with memory measures, level of arousal was evaluated through clinical ratings and nonverbal self-ratings in epilepsy patients undergoing IAT before anterior temporal lobectomy.

Results: Irrespective of seizure focus, left-sided amobarbital injection resulted in decreased objective and subjective arousal more often than right-side injection. Impaired objective arousal was greater when the left hemisphere was injected second, because of the presumed additive effects of systemic amobarbital residual from the first injection. Decreased objective arousal was related to poorer performance on memory testing following left-hemisphere injection.

Conclusions: The IAT, as practiced in most centers, is biased, so patients with right temporal lobe seizure focus are more likely to “pass” the test, whereas patients with left seizure focus are more likely to “fail” the test. The significant impact of changes in arousal on memory testing needs to be considered when using IAT results to select patients for temporal lobectomy.

OIL FLAIR: optimized interleaved fluid-attenuated inversion recovery in 2D fast spin echo

Inversion recovery may be used to suppress signal from cerebrospinal fluid, a technique which has been named "fluid attenuated with inversion recovery" (FLAIR). This report describes interleaving a slice selective inversion pulse within a rapid spin-echo sequence to obtain the desirable contrast characteristics of FLAIR in imaging times comparable to standard rapid spin echo. Additionally, the pulse repetition time is allowed to float above a defined minimum, which can further shorten scan times and dramatically ease the optimization process. The optimized interleaved sequence is referred to as OIL FLAIR.

Unusual behavior of clear cell chondrosarcoma

We report two unusual cases of clear cell chondrosarcoma. Both emphasize the slow-growing nature of the lesion and the need for long-term follow-up. Additionally, the clinical, radiologic and histologic characteristics of this neoplasm are discussed.