Effectiveness of Preradiosurgical Embolization with NBCA for Arteriovenous Malformations - Retrospective Outcome Analysis in a Japanese Registry of 73 Patients (J-REAL study) / 신경중재치료의학

PURPOSE: Recent reports have posed doubts about the effect of preradiosurgical embolization in brain arteriovenous malformation (AVM) because it makes the planning of stereotactic radiosurgery (SRS) difficult and has the risk of recanalization out of the target. We investigated whether the performance and quality of embolization may influence the success of SRS based on a retrospective case cohort study. MATERIALS AND METHODS: Seventy-three patients who underwent embolization followed by SRS between 2003 and 2012 in eight institutes with neurointerventionists were considered. They were divided into the following two groups at 3 years of follow up after the final SRS: “successful occlusion group” (S group), with radiologically complete occlusion of AVM; and “non-successful occlusion group” (N group) with persistent remnant nidus or abnormal vascular networks. Patient background, AVM profile, embolization performance grade and complications were compared in each group. The quality of embolization was evaluated with the new grading system: embolization performance grade (E grade), specializing the achievement of nidus embolization. E grade A was defined as sufficient nidus embolization with more than half of the total number of feeders achieving nidus penetration. E grade B was defined as less than half achievement of nidus embolization, and E grade C was defines as failure to perform nidus embolization. RESULTS: Forty-three patients were included in the S group, and 29 patients were included in the N group. The size and Spetzler-Martin grade of AVM and the rate of diffuse type was higher in the N group without statistical significance. The embolization performance level according to E grade indicated a significantly higher rate of successful embolization with more than 50% of nidus penetration in the S group (P<0.001). This difference was also confirmed in the subanalysis for limited cases, excluding smaller AVMs with complete occlusion with SRS alone (P=0.001). CONCLUSION: The cause of the unsuccessful result of post-embolization SRS might be the large, diffuse angioarchitecture, but proper embolization with a high rate of nidus penetration to avoid recanalization is more important. Effective embolization is essential to contribute to and promote the effect of radiosurgery.

Analysis of clinicians’ needs for lifelong learning / 医学教育

Introduction: Lifelong learning is important for physicians because of patient safety and the need to constantly improve the quality of medical practice. However, few studies have investigated the specific topics that are required.<br>Methods: We examined the lifelong learning needs of physicians by means of a self-administered questionnaire that was completed by 595 subjects, who were clinical practitioners working in Gunma Prefecture.<br>Results: Subjects of all ages needed lectures about the use of evidence-based medicine in medical examinations, clinical studies and the interpretation of epidemiological data, and diagnostic imaging. The younger subjects had a greater need for learning about clinical skills and techniques, such as advanced cardiac life support／intensive care life support, abdominal ultrasonic diagnosis, and cardiac ultrasonic diagnosis. Regarding the ideal times for these lectures, some physicians working at Gunma University Hospital expressed a preference for weekdays after normal business hours, while others preferred the weekends.<br>Discussion: The lifelong learning needs of physicians were clarified. Because physicians work on different shifts and at different institutions, scheduling training sessions that everyone can attend is difficult, especially for those who are off-campus. The timing of the training sessions, as well as the content of lectures, must be considered. Ideally, sessions should be held more than once to accommodate the busy schedules of physicians. We believe that providing an opportunity for lifelong learning will help attract more people to a career in medicine and thereby help address the physician shortage.

A Unique Type of Dural Arteriovenous Fistula at Confluence of Sinuses Treated with Endovascular Embolization: A Case Report / 신경중재치료의학

Dural arteriovenous fistula (DAVF) is classically defined as abnormal arteriovenous connections located within the dural leaflets. Though the exact etiology is still not clear, they are generally accepted as acquired lesions. However, some DAVFs formed as the congenital disorders are called dural arteriovenous malformations and these lesions with a marked cortical venous reflux are considered to be aggressive and warrant an early intervention. The authors describe a case of 35-year-old man presented with unique type of DAVF. The fistula was located adjacent to the confluence of venous sinuses with multiple feeders. The feeders drained into a large venous pouch just anterior to the confluence which had a bilateral venous drainage. This was associated with multiple cerebellar venous ectasia along the draining cortical vein. It was managed by staged endovascular procedures and complete cure could be achieved. The pathogenesis and technique of embolization of this complex fistula/malformation are also discussed.

Analysis of the needs of clinicians returning to clinical practice: / 医学教育

Introduction and Methods: An immediate effect of the physician shortage is the return to clinical work by physicians who had earlier left. Therefore, the needs of returning physicians were examined by means of a self-administered questionnaire. The subjects were clinicians working in Gunma Prefecture.<br>Results: About 50% of female physicians and 25% of male physicians had left clinical practice. The reasons given for leaving were “studying abroad” for most male physicians and “pregnancy and child-rearing” for most female physicians. More than 70% of physicians who had left clinical work felt uneasy about returning. The degree of anxiety after returning did not differ significantly between male and female physicians. Problems encountered by returning physicians involved “changes in medicines,” “changes and progress in technology and medical theories,” and deterioration of their “skills and techniques.” Moreover, returning physicians felt a need for increased “practical skills training.”<br>Discussion: Our study has clarified the needs of physicians returning to clinical work. The development and adoption of a simple system that will help physicians return to clinical practice is required.