Efficacy of Epidural Blood Patching or Surgery in Spontaneous Intracranial Hypotension: A Systematic Review and Evidence Map.

BACKGROUND: Spontaneous intracranial hypotension is an important cause of treatable secondary headaches. Evidence on the efficacy of epidural blood patching and surgery for spontaneous intracranial hypotension has not been synthesized. PURPOSE: Our aim was to identify evidence clusters and knowledge gaps in the efficacy of treatments for spontaneous intracranial hypotension to prioritize future research. DATA SOURCES: We searched published English language articles on MEDLINE (Ovid), the Web of Science (Clarivate), and EMBASE (Elsevier) from inception until October 29, 2021. STUDY SELECTION: We reviewed experimental, observational, and systematic review studies assessing the efficacy of epidural blood patching or surgery in spontaneous intracranial hypotension. DATA ANALYSIS: One author performed data extraction, and a second verified it. Disagreements were resolved by consensus or adjudicated by a third author. DATA SYNTHESIS: One hundred thirty-nine studies were included (median, 14 participants; range, 3-298 participants). Most articles were published in the past decade. Most assessed epidural blood patching outcomes. No studies met level 1 evidence. Most were retrospective cohort or case series (92.1%, n = 128). A few compared the efficacy of different treatments (10.8%, n = 15). Most used objective methods for the diagnosis of spontaneous intracranial hypotension (62.3%, n = 86); however, 37.7% (n = 52) did not clearly meet the International Classification of Headache Disorders-3 criteria. CSF leak type was unclear in 77.7% (n = 108). Nearly all reported patient symptoms using unvalidated measures (84.9%, n = 118). Outcomes were rarely collected at uniform prespecified time points. LIMITATIONS: The investigation did not include transvenous embolization of CSF-to-venous fistulas. CONCLUSIONS: Evidence gaps demonstrate a need for prospective study designs, clinical trials, and comparative studies. We recommend using the International Classification of Headache Disorders-3 diagnostic criteria, explicit reporting of CSF leak subtype, inclusion of key procedural details, and using objective validated outcome measures collected at uniform time points.

High accuracy plasma density measurement using hybrid Langmuir probe and microwave interferometer method.

High spatial resolution plasma density measurements have been taken as part of an investigation into magnetic nozzle physics at the NASA/MSFC Propulsion Research Center. These measurements utilized a Langmuir triple probe scanned across the measurement chord of either of two stationary rf interferometers. By normalizing the scanned profile to the microwave interferometer line-integrated density measurement for each electrostatic probe measurement, the effect of shot-to-shot variation of the line-integrated density can be removed. In addition, by summing the voltage readings at each radial position in a transverse scan, the line density can be reconstituted, allowing the absolute density to be determined, assuming that the shape of the profile is constant from shot to shot. The spatial and temporal resolutions of this measurement technique depend on the resolutions of the scanned electrostatic probe and the interferometer. The measurement accuracy is 9%-15%, which is on the order of the accuracy of the rf interferometer. The measurement technique was compared directly with both scanning rf interferometer and standard Langmuir probe theory. The hybrid technique compares favorably with the scanning rf interferometer, and appears more accurate than probe theory alone. Additionally, our measurement technique is generally applicable even for nonaxisymmetric plasmas.

Case study: unionization of a newly acquired satellite practice.

In March 1997, a 24-physician primary care medical group in upstate New York acquired an occupational medicine practice. Shortly after the merger, motivated primarily by job security concerns, the employees of the occupational medicine group voted to unionize for the purpose of collective bargaining. The author--the practice manager for the merged medical group--describes the events that ensued as practice management and union employees struggled toward an agreement.

Pediatric headaches: what do the children want?

One hundred consecutive children (aged 3 to 17 years), drawn from primary care pediatric clinics, with a greater than 3-month history of headaches completed surveys to determine the type and associated features of their headache and to query their reasons for wanting to see a physician. Additionally, the children were asked to draw pictures of how they felt when they had a headache to assess their nonverbal perceptions. Over 90% of the headaches were migrainous (65% common, 23% classic, 5% basilar). The children wanted three answers from the physician: what was the cause of their headache, what would make it better, and reassurance that they had no life-threatening illness. Furthermore, 33% of the children's illustrations disclosed depressive features of helplessness, frustration, and anger. Over 20% of the adolescents depicted themselves as dead, dying, or about to be killed by their headache.

Prevalence and clinical significance of dilated Virchow-Robin spaces in childhood.

PURPOSE: To determine the prevalence and clinical significance of dilated Virchow-Robin spaces in pediatric patients. MATERIALS AND METHODS: Cranial magnetic resonance (MR) studies of 1,250 children who underwent imaging during 12 consecutive months were prospectively evaluated. RESULTS: Thirty-seven patients had prominent Virchow-Robin spaces. The most common indications for imaging in these patients were headache (n = 10), developmental delay (n = 8), and psychiatric problems (n = 7). Medical records revealed that 12 of the 37 patients had severe headaches, 17 had moderate or severe delay in development, and 18 had serious behavioral or psychiatric problems. An association was found between presence or absence of dilated Virchow-Robin spaces and presence or absence of developmental delay (odds ratio = 4.9; 95% confidence interval [CI] = 2.1, 11.1; P < .001), psychiatric problems (odds ratio = 12.6; 95% CI = 5.0, 31.8; P < .001), and headaches (odds ratio = 37; 95% CI = 14.7, 93.2; P < .001). CONCLUSION: There appears to be a correlation between functional neuropsychiatric disorders in children and the presence of Virchow-Robin spaces in the cerebral hemispheres at MR imaging.

Synthesis of the allylic gonadal steroids, 3 alpha-hydroxy-4-pregnen-20-one and 3 alpha-hydroxy-4-androsten-17-one, and of 3 alpha-hydroxy-5 alpha-pregnan-20-one.

A method for the convenient synthesis of the recently isolated allylic gonadal steroids, 3 alpha-hydroxy-4-pregnen-20-one (3 alpha-dihydroprogesterone; 3 alpha-DHP) and 3 alpha-hydroxy-4-androsten-17-one (3 alpha-HA), was developed using 4-pregnene-3,20-dione (progesterone) and 4-androstene-3,17-dione as substrates and potassium trisiamylborohydride (KS-Selectride) as reducing agent. Similar reactions were also used for the reduction of 5 alpha-pregnane-3,20-dione to 3 alpha-hydroxy-5 alpha-pregnan-20-one (3 alpha-HP). The yields were about 15%, 50%, and greater than 90% for 3 alpha-DHP, 3 alpha-HA and 3 alpha-HP, respectively. Structures of the products, including the 3 beta-isomers and the 17 alpha-epimer, formed in these reactions were determined by NMR and mass spectroscopic methods.