A Multicenter Study Investigating the Surgeon Experience with a Robotic-Assisted Exoscope as Part of the Neurosurgical Armamentarium.

BACKGROUND: Improvement of visualization tools in neurosurgery such as the exoscope has raised the question of how this technology compares to the conventional microscope for surgeon ergonomics, discomfort, and patient outcomes. Exoscopes have the advantage of greater optical zoom, resolution, and illumination at a lower light intensity. Heads-up display for both the primary surgeon and other assistants permits neutral positioning of the surgeons while placing the camera in more angled positions. In a survey sample, this study assesses the surgeon experience utilizing 3D exoscope in general neurosurgery cases. METHODS: Data weere recorded by 8 surgeons at 5 separate hospitals utilizing a mobile phone application survey. Surgeons recorded information about case type, intraoperative clinical outcomes such as blood loss and extent of resection, whether fluorescence visualization was used, as well as surgeon pain when compared to matched cases using conventional tools. RESULTS: A total of 155 neurosurgical cases were recorded in this multisite study, including 72% cranial cases and 28% spinal cases. Of the cranial cases, 76% were brain tumor resections (31% of which were brain metastases). Surgeons reported significantly less neck (P < 0.0001) and back (P < 0.0001) pain in cases when using the robotic exoscope compared with the conventional microscope or surgical loupes. Surgeons did not convert to a microscope in any case. CONCLUSIONS: The exoscope provides excellent delineation of tissue with high resolution. Surgeon pain was markedly reduced with the robotic exoscope when compared with conventional technology, which may reduce work-related injury and fatigue, potentially leading to better patient outcomes.

Adolescentes e conduta infracional: espaços, equipamentos e conteúdos de esporte e lazer / Adolescents and infraction conduct: sport and leisure spaces, equipment and content / Adolescentes y conducta infractora: espacios, equipos y contenidos de deporte y recreación

Este estudo exploratório e descritivo tem por objetivo identificar os espaços, equipamentos e conteúdos de esporte e lazer de um município do estado de Mato Grosso, com maior incidência de adolescentes em cumprimento de medida socioeducativa de internação nos anos de 2017 e 2018. Os dados foram disponibilizados pela Gestão Estadual do Sistema de Informação para Infância e Adolescência (SIPIA). Realizaram-se observações in loco em oito bairros, utilizando categorias de análise predefinidas para registros em diário de campo. Os resultados demonstram a escassa oferta de espaços, equipamentos e conteúdos de esporte e lazer disponibilizados aos adolescentes dessas comunidades. Diante desse cenário, a falta de acesso às políticas de esporte e lazer pode configurar como possível fator de risco ao cometimento de ato infracional no contexto pesquisado, além da exposição dos jovens ao mesmo risco ao retornarem à comunidade.

This exploratory and descriptive study aims to identify sports and leisure spaces, equipment and contents of a municipality in the Brazilian state of Mato Grosso with higher incidence of adolescents sentenced to socio-educational internment in 2017 and 2018. Data were provided by the State Management of the Children and Adolescents Information System (SIPIA). On-site observation was carried out in eight neighborhoods, using predefined analytical categories for field diary records. The results point to scarce offer of sport and leisure spaces, equipment and content in those communities. In view of this scenario, the study concludes that the lack of access to sports and leisure policies is seen as a possible risk factor for committing infractions in the context researched, in addition to exposing young people to the same risk when they return to their communities.

Este estudio exploratorio y descriptivo tiene por objetivo identificar los espacios, equipos y contenidos de deporte y recreación de un municipio del estado de Mato Grosso que tiene mayor incidencia de adolescentes en cumplimiento de medida socioeducativa de internación durante los años 2017 y 2018. Los datos fueron puestos a disposición por la Administración Estatal del Sistema de Información para Infancia y Adolescencia (SIPIA). Se realizaron observaciones in situ en ocho barrios, utilizando categorías de análisis predefinidas para registros en diario de campo. Los resultados demuestran la escasa oferta de espacios, equipos y contenidos de deporte y recreación que se ofrece a los adolescentes de esas comunidades. Ante este escenario, la falta de acceso a políticas de deporte y recreación puede configurarse como posible factor de riesgo para cometer infracciones en el contexto investigado, además de exponer a los jóvenes al mismo riesgo cuando regresan a la comunidad.

Esporte e lazer no plano individual de atendimento de adolescentes em cumprimento de medida socioeducativa de internação / Sport and leisure in the individual plan of adolescent care in compliance with court-mandated social-educative internment / Deporte y recreación en el plan individual de asistencia para adolescentes en cumplimiento de medida socioeducativa de internación

Esta pesquisa documental tem por objetivo compreender o acesso ao esporte e lazer na trajetória de adolescentes em cumprimento de medida socioeducativa de internação no estado de Mato Grosso. Foram analisados 36 Planos Individuais de Atendimento (PIA) de sete Centros de Atendimento Socioeducativo, elaborados entre os anos de 2017-2018 e disponibilizados pela Gestão Estadual do Sistema para Infância e Adolescência - SIPIA/SINASE/MT. Os dados relacionados aos eixos esporte e lazer foram analisados através da análise de conteúdo. O perfil dos adolescentes retrata os problemas socioeconômicos e de vulnerabilidade social presentes na contemporaneidade. A partir das categorias de análise observou-se a restrita oferta dessas políticas de atendimento na trajetória dos adolescentes. Conclui-se que o cumprimento da medida socioeducativa de internação propiciou maior acesso aos espaços, equipamentos e conteúdos de esporte e lazer aos adolescentes, se comparado com suas vivências anteriores à aplicação da medida.

This research aims to understand the access to sports and leisure in adolescents' lives in compliance with court-mandated social-educative internment in the state of Mato Grosso. Thirty-six Individual Care Plans of seven Socio-Educational Care Centers were examined, which had been created between 2017-2018 and publicized by the State Management of the System for Childhood and Adolescence - SIPIA/SINASE/MT. Data related to sports and leisure were submitted to content analysis. The adolescents' profiles show today's socioeconomic problems and social vulnerability. Based on the categories of analysis, the offer of these care policies in the adolescents' lives was observed to be restricted. Compliance to court-mandated social-educative internment is found to provide greater access to sports and leisure spaces, equipment and contents to the adolescents when compared to their experiences before the sentence.

Este estudio tiene por objetivo comprender el acceso al deporte y a la recreación de adolescentes que cumplen medidas socioeducativas de internación en el Estado de Mato Grosso. Se analizaron 36 Planes Individuales de Asistencia (PIA) de siete Centros de Asistencia Socioeducativa, elaborados en los años 2017 y 2018 y puestos a disposición por la Administración Estatal del Sistema para la Infancia y Adolescencia - SIPIA/SINASE/MT. Los datos relacionados a los ejes deportes y recreación se analizaron a través de la metodología de análisis de contenido. El perfil de los adolescentes retrata los problemas socioeconómicos y de vulnerabilidad social presentes actualmente. A partir de las categorías de análisis, se observó una oferta limitada de estas políticas de asistencia en la trayectoria de los adolescentes. Se concluye que el cumplimiento de medidas socioeducativas de internación propició un mayor acceso a los espacios y contenidos de deporte y recreación a los adolescentes, en comparación con sus experiencias previas a la aplicación de las medidas.

The Effects of Clinically Relevant Hypertonic Saline and Conivaptan Administration on Ischemic Stroke.

Cerebral edema after stroke is associated with poor neurological outcomes. Current therapies are limited to osmotic agents, such as hypertonic saline (HS), which reduce intracranial pressure. Although studies have demonstrated edema reductions following HS, tissue survival has not been thoroughly examined. Additionally, the efficacy of promising pharmacological agents has not been evaluated for synergy with osmotic agents. Conivaptan is an FDA-approved vasopressin receptor antagonist that may exert both osmotic and anti-inflammatory effects. In this study, rats were subjected to middle cerebral artery occlusion prior to treatment with 5 % HS bolus +5 % HS maintenance (HS), conivaptan alone (Con), conivaptan +5 % HS maintenance (Con + HS), or conivaptan +5 % HS bolus +5 % maintenance (Con + HSb). Treatments were initiated at six (Early) or 24 h (Late) following stroke and rats were euthanized at 48 h to evaluate infarct volume, brain edema, and microglia/macrophage activation. Infarct volume and brain edema in the Early HS, Early Con, and Late HS groups were significantly reduced compared with controls. Interestingly, only the Early Con group demonstrated reduced microglia/macrophage activation. These data suggest an anti-inflammatory mechanism for conivaptan and provide support for a multipronged approach combining osmotic agents with compounds that inhibit the neuroinflammatory response to stroke.

C-shaped Incision for Far-Lateral Suboccipital Approach: Anatomical Study and Clinical Correlation.

Background The standard incision for far-lateral suboccipital approaches has been the classic "reverse hockey stick." Although that incision provides ample exposure, concern has been raised that excessive muscle dissection and skin elevation might lead to accumulation of cerebrospinal fluid (CSF) under the flap with increased risk of CSF leak. We hypothesize that the C-shaped incision can minimize the amount of muscle dissection and provide optimal exposure and surgical outcomes. Objective To describe the anatomical dissection for the C-shaped incision and clinical application of the C-shaped incision for the far-lateral approach. Methods A retrospective analysis of all the patients operated on at our center using this approach for the treatment of aneurysm of the posterior inferior cerebellar artery (PICA) from 2005 to 2011. Results of clinical and operative outcome are evaluated. Surgical techniques are described in detail. Cadaveric dissections using the C-shaped incision were performed to assess the exposure of the far-lateral suboccipital area. Results Eleven consecutive patients who had undergone this procedure were selected. All patients underwent clipping of PICA aneurysms. Nine patients (82%) presented with ruptured aneurysms and subarachnoid hemorrhage. All of them underwent suboccipital craniectomy and C1 laminectomy. The dura mater was closed in a watertight fashion in 10 patients (91%). No CSF leak or pseudomeningocele were reported. In nine SAH patients, two (22%) had postoperative dysphagia and required long-term percutaneous endoscopic gastrostomy tube placement. One patient (11%) had chronic respiratory failure and required a tracheostomy. Three patients (33%) developed hydrocephalus and required a ventriculoperitoneal shunt. Conclusions The C-shaped incision is a valid alternative to the classic reverse hockey-stick incision to gain exposure for far-lateral craniotomies. Knowing the anatomy and dissection techniques can provide an easy and safe route to address anterior lateral cranial-cervical lesions. Our results suggest the C-shaped incision is reliable in preventing CSF leak and the formation of pseudomeningocele.

Paradoxical trends in the management of vestibular schwannoma in the United States.

OBJECT: Recent natural history studies of vestibular schwannomas (VSs) suggest that most of these tumors do not grow. The impact of these new data on management trends in the US is currently unknown. The aim in the present study was to evaluate current trends in the treatment of VS in the US by analyzing a national cancer database. METHODS: The Surveillance, Epidemiology, and End Results Program is a national database maintained by the National Cancer Institute representing 26% of the US population. Data from the database were downloaded using provided software. Cases were isolated based on histology codes and the site code. Data from 2004 to 2007 were included in the analysis. The number of patients undergoing resection was compared with the number treated with beam radiation and observation, based on tumor size. RESULTS: Three thousand six hundred fifty cases were identified in the database. Over the study period, management choices for VSs showed a significant change only for tumors with a diameter < 2 cm. In this tumor category, a decrease in resection and an increase in radiation were observed, with observation showing a modest increase but remaining low at an average of 25%. CONCLUSIONS: Study data demonstrated a shift in the management of small VSs in the US between 2004 and 2007, with microsurgical removal giving way to radiation treatment and the overall rate for observation remaining low and stable. With recent literature suggesting that the majority of small tumors do not grow, the authors assert that VSs are being overtreated in the US.

The frontotemporal-orbitozygomatic approach: reconstructive technique and outcome.

BACKGROUND: The frontotemporal-orbitozygomatic (FTOZ) approach, also known as "the workhorse of skull base surgery," has captured the interest of many researchers throughout the years. Most of the studies published have focused on the surgical technique and the gained exposure. However, few studies have described reconstructive techniques or functional and cosmetic outcomes. The goal of this study was to describe the surgical reconstruction after the FTOZ approach and analyze the functional and cosmetic outcomes. METHODS: Seventy-five consecutive patients who had undergone FTOZ craniotomy for different reasons were selected. The same surgical (one-piece FTOZ) and reconstructive techniques were applied in all patients. The functional outcome was measured by complications related to the surgical approach: retro-orbital pain, exophthalmos, enophthalmos, ocular movement restriction, cranial nerve injuries, pseudomeningocele (PMC) and secondary surgeries required to attain a reconstructive closure. The cosmetic outcome was evaluated by analyzing the satisfaction of the patients and their families. Questionnaires were conducted later in the postoperative period. A statistical analysis of the data obtained from the charts and questions was performed. RESULTS: Of the 75 patients studied, 59 had no complications whatsoever. Ocular movement restriction was found in two patients (2.4 %). Cranial nerve injury was documented in seven patients (8.5 %). One patient (1.2 %) underwent surgical repair of a cerebrospinal fluid (CSF) leak from the initial surgery. Two patients (2.4 %) developed delayed postoperative pseudomenigocele. One patient (1.2 %) developed intraparenchymal hemorrhage (IPH). Full responses to the questionnaires were collected from 28 patients giving an overall response rate of 34 %. Overall, 22 patients (78.5 %) were satisfied with the cosmetic outcome of surgery. CONCLUSION: The reconstruction after FTOZ approach is as important as the performance of the surgical technique. Attention to anatomical details and the stepwise reconstruction are a prerequisite to the successful preservation of function and cosmesis. In our series, the orbitozygomatic osteotomy did not increase surgical complications or alter cosmetic outcomes.

Treatment of vertebral artery origin stenosis with anti-proliferative drug-eluting stents.

BACKGROUND: Vertebral artery origin stenosis is a known cause of stroke that is treatable with angioplasty and stenting. Previous studies have demonstrated that this technique is safe but is limited by high rates of in-stent stenosis. Anti-proliferative drug-eluting stents are an alternative for reducing in-stent stenosis at the vertebral artery origin. METHODS: This retrospective study included five consecutive patients treated with anti-proliferative drug-eluting stents. The patients' demographics, indications for treatment, procedural technique, and clinical and radiographic follow-up are presented along with a review of the literature. RESULTS: No peri-procedural complications occurred. One patient had a transient ischemic attack (TIA) during the follow-up period. No patients had hemodynamically significant (>50%) in-stent stenosis at follow-up. Among the 287 cases reported in the literature, there were two strokes (.7%), four TIAs (1.4%), and no procedurally related deaths. Among patients undergoing angiographic follow-up, 26% were found to have >50% in-stent stenosis. CONCLUSIONS: Anti-proliferative drug-eluting stents hold promise for reducing in-stent stenosis at the vertebral artery origin.