A decade of improvement in the management of New Zealand ST-elevation myocardial infarction (STEMI) patients: results from the New Zealand Acute Coronary Syndrome (ACS) Audit Group national audits of 2002, 2007 and 2012.

AIMS: To audit the management of ST-segment elevation myocardial infarction (STEMI) patients admitted to a New Zealand Hospital over three 14-day periods to review their number, characteristics, management and outcome changes over a decade. METHODS: The acute coronary syndrome (ACS) audits were conducted over 14 days in May of 2002, 2007 and 2012 at New Zealand Hospitals admitting patients with a suspected or definite ACS. Longitudinal analyses of the STEMI subgroup are reported. RESULTS: From 2002 to 2012, the largest change in management was the proportion of patients undergoing reperfusion by primary PCI from 3% to 15% and 41%; P<0.001, and the rates of second antiplatelet agent use in addition to aspirin from 14% to 62% and 98%; P<0.001. The use of proven secondary prevention medications at discharge also increased during the decade. There were also significant increases in cardiac investigations for patients, especially echocardiograms (35%, 62% and 70%, P<0.001) and invasive coronary angiograms (31%, 58% and 87%, P<0.001). Notably even in 2012, one in four patients presenting with STEMI did not receive any reperfusion therapy. CONCLUSIONS: Substantial improvements have been seen in the management of STEMI patients in New Zealand over the last decade, in accordance with evidenced-based guideline recommendations. However, there appears to be considerable room to optimise management, particularly with the use of timely reperfusion therapy for more patients.

Intraoperative Ultrasound Technology in Neuro-Oncology Practice-Current Role and Future Applications.

BACKGROUND: Surgery for cranial and spinal tumors has evolved tremendously over the years. Not only have neuro-oncologists been able to better understand tumor biology and thereby improve multimodality therapy, but advances in surgical techniques have also directly equipped neurosurgeons with the armamentarium necessary to achieve more radical resections safely. Intraoperative imaging tools are one such adjunct. Though intraoperative magnetic resonance (MR) has emerged as the "gold standard" among these, logistical challenges make it difficult to implement across all centers. On the other hand, the use of ultrasound (US) intraoperatively predates the use of MR. Over the past 4 decades, technologic improvements have refined and expanded the scope and application of intraoperative US technology. Strategies to maximize its efficacy and overcome the various limitations have evolved. A large volume of clinical experience has accumulated with respect to its role as an adjunct specifically in tumor surgery. METHODS: We performed a literature review to evaluate the role of IOUS in tumor surgery. This review traces the evolution of intraoperative US over the years and reviews the current scope and applications with respect to neuro-oncologic surgery, as well as potential future applications. RESULTS: IOUS has evolved over the years since its introduction. Advances in technology have provided real-time navigated and 3-D techniques, which overcome many of the limitations of older IOUS techniques. This has shown to be very useful in not only localization of lesions, but also in improving resection rates as well as survival. CONCLUSIONS: IOUS is a powerful and versatile multipurpose intraoperative adjunct in tumor surgery, especially for resection control. The learning curve is relatively easy to climb and future improvements in technology are likely to widen the scope of its use.

Progress in Neonatal Neurology with a Focus on Neuroimaging in the Preterm Infant.

There have been tremendous changes in the methods used to evaluate brain injury in the preterm infant in the past 30 years. In particular, major improvements have been made in how we use neuroimaging techniques and now magnetic resonance imaging (MRI) is used more often and considered complimentary to routine and sequential cranial ultrasound. The focus has shifted from severe lesions such as large intraventricular and parenchymal hemorrhages and cystic periventricular leukomalacia to assessing and understanding the etiology of more subtle noncystic white matter injury, punctate hemorrhage, and cerebellar lesions. The more severe lesions that dominated the early period of preterm neonatal brain imaging occur less frequently but are still associated with major disabilities, such as, cerebral palsy, while subtle white matter injury and cerebellar lesions are more often associated with cognitive and behavioral problems, which have become the most prevalent issues among the survivors of extremely preterm birth.

Intra-operative 3D ultrasound in neurosurgery.

In recent years there has been a considerable improvement in the quality of ultrasound (US) imaging. The integration of 3D US with neuronavigation technology has created an efficient and inexpensive tool for intra-operative imaging in neurosurgery. In this review we present the technological background and an overview of the wide range of different applications. The technology has so far mostly been applied to improve surgery of tumours in brain tissue, but it has also been found to be useful in other procedures such as operations for cavernous haemangiomas, skull base tumours, syringomyelia, medulla tumours, aneurysms, AVMs and endoscopy guidance.

Future perspectives in intraoperative imaging.

Of all the advances in imaging science in the past twenty years, none has had a greater impact than Magnetic Resonance Imaging. Since its introduction as a diagnostic tool in the mid-1980's, MRI has evolved into the premier neuroimaging modality, and with the addition of higher field magnets, we are able to achieve spatial resolution of such superb quality that even the most exquisite details of the brain anatomy can be visualized. With the implementation of intraoperative, neurosurgical MRI, we can not only monitor brain shifts and deformations; we can achieve intraoperative navigation using intraoperative image updates. In the future, intraoperative MRI can be used not only to localize, target, and resect brain tumors and other lesions but also to fully comprehend the surrounding cortical and white matter functional anatomy. In addition to the inclusion of new imaging methods such as diffusion tensor imaging, new therapeutic methods will be applied. Especially encouraging are the promising results in MRI-guided Focused Ultrasound Surgery, in which the non-invasive thermal ablation of tumors is monitored and controlled by MRI. With the clinical introduction of these advances, intraoperative MRI is changing the face of Neurosurgery today.

Cerebral Doppler sonography of the neonate. A résumé after 20 years and future aspects.

Up until recently the evaluation of CVR (analysis of pulsatility) had been a priority in Doppler sonography. In preterm and term infants with open fontanels and sutures this information is restricted despite its value in extreme situations. Continuous Doppler sonography allows a new approach to monitoring pathophysiologic processes. In connection with improved data recording and processing as well as progress in monitoring blood pressure and central venous pressure, new noninvasive methods of surveillance become possible. Thanks to these methods experimental and clinical research has increasingly gained insight on the autonomic nervous system over the last few years (e.g., m- and r-wave analysis during continuous measurement of arterial blood pressure and heart rate). Already well-known and newly developed functional tests (e.g., tilting test, CO2-reactivity, phase shift, and so forth) will further improve our understanding of physiologic processes and help us develop individual therapy concepts for the newborn.