A comparison of clinical characteristics, radiographic findings, and outcomes of bihemispheric versus unihemispheric gunshot wounds to the head.

INTRODUCTION: Unihemispheric head gunshot wound (HGSW) are associated with improved survival; however, specific clinical and radiographic characteristics associated with survival have not been clearly defined. To further guide prognosis estimates and care discussions, this study aims to identify unihemispheric HGSWs injury patterns; comparing them to bihemispheric HGSWs characterizing factors associated with improved clinical outcomes and survival. METHODS: Patients presenting to our Level 1 trauma center from January 2013 through May 2019 with HGSW injury were reviewed. Patients were grouped into those with unihemispheric versus bihemispheric HGSWs and survivors versus non-survivors. Clinical variables and head computed tomography (CT) features were compared using comparative statistics. RESULTS: 62 HGSW patients met study criteria (unihemispheric = 33, bihemispheric = 29). Regardless of injury type, avoidance of injury to multiple lobes, temporal, parietal and basal ganglia brain regions and intracranial vascular injury were also associated with survival (p < 0.05). Lower admission GCS score and lower motor GCS score was associated with reduced survival in unihemispheric HGSW injury (p < 0.05). Unihemispheric HGSW survivors demonstrated improved clinical outcomes, with reduced hospital length of stay (5 days vs. 47 days, p = 0.014) and intensive care unit length of stay (3 days vs. 20 days, p = 0.021) and more favorable disposition location. CONCLUSION: We found presenting clinical features and CT imaging patterns previously associated with improved survival in HGSW patients is similar in unihemispheric specific injuries. Importantly, a more favorable admission GCS score may portend survivability in unihemsipheric HGSW. Furthermore, unihemispheric HGSW survivors may have improved clinical outcomes, length of stay and disposition location.

Femoral nerve neuromonitoring for lateral lumbar interbody fusion surgery.

BACKGROUND CONTEXT: The transpsoas lateral lumbar interbody fusion (LLIF) technique is an effective alternative to traditional anterior and posterior approaches to the lumbar spine; however, nerve injuries are the most reported postoperative complication. Commonly used strategies to avoid nerve injury (eg, limiting retraction duration) have not been effective in detecting or preventing femoral nerve injuries. PURPOSE: To evaluate the efficacy of emerging intraoperative femoral nerve monitoring techniques and the importance of employing prompt surgical countermeasures when degraded femoral nerve function is detected. STUDY DESIGN/SETTING: We present the results from a retrospective analysis of a multi-center study conducted over the course of 3 years. PATIENT SAMPLE: One hundred and seventy-two lateral lumbar interbody fusion procedures were reviewed. OUTCOME MEASURES: Intraoperative femoral nerve monitoring data was correlated to immediate postoperative neurologic examinations. METHODS: Femoral nerve evoked potentials (FNEP) including saphenous nerve somatosensory evoked potentials (snSSEP) and motor evoked potentials with quadriceps recordings were used to detect evidence of degraded femoral nerve function during the time of surgical retraction. RESULTS: In 89% (n=153) of the surgeries, there were no surgeon alerts as the FNEP response amplitudes remained relatively unchanged throughout the surgery (negative group). The positive group included 11% of the cases (n=19) where the surgeon was alerted to a deterioration of the FNEP amplitudes during surgical retraction. Prompt surgical countermeasures to an FNEP alert included loosening, adjusting, or removing surgical retraction, and/or requesting an increase in blood pressure from the anesthesiologist. All the cases where prompt surgical countermeasures were employed resulted in recovery of the degraded FNEP amplitudes and no postoperative femoral nerve injuries. In two cases, the surgeons were given verbal alerts of degraded FNEPs but did not employ prompt surgical countermeasures. In both cases, the degraded FNEP amplitudes did not recover by the time of surgical closure, and both patients exhibited postoperative signs of sensorimotor femoral nerve injury including anterior thigh numbness and weakened knee extension. CONCLUSIONS: Multimodal femoral nerve monitoring can provide surgeons with a timely alert to hyperacute femoral nerve conduction failure, enabling prompt surgical countermeasures to be employed that can mitigate or avoid femoral nerve injury. Our data also suggests that the common strategy of limiting retraction duration may not be effective in preventing iatrogenic femoral nerve injuries.

An online survey of Irish general practitioner experience of and attitude toward managing problem alcohol use.

BACKGROUND: In the general practice setting screening, brief intervention and counselling have been shown to be effective in the reduction of problem alcohol use. This study aimed to explore Irish general practitioners' (GPs) current practice of and attitudes towards the management of problem alcohol use. METHODS: An online survey was emailed, with one email reminder, to 1750 general/family practitioners who were members of the Irish College of General Practitioners (ICGP) and for whom an active email address was available. Overall, 476 completed questionnaires were received representing a 27.2% response rate. RESULTS: Two-thirds of the respondents reported that they have managed patients for problem alcohol use and related issues in the past year. The majority, 96%, of respondents indicated that they initiate conversations around alcohol even when the patient does not do so. Almost two thirds of GPs stated that they use structured brief intervention when talking to patients about their alcohol intake and circa 85% reported that they provide some form of counselling in relation to reducing alcohol consumption. While more than two out of three GPs felt prepared when counselling patients in relation to alcohol consumption, almost half considered they are ineffective in helping patients to reduce alcohol consumption. One third of GPs advised that they did not have access to an addiction counsellor. CONCLUSIONS: GPs in this survey reported widespread experience of screening and intervention, however, many still felt ineffective. In order to maximise the potential impact of GPs, a clearer understanding is required of what interventions are effective in different scenarios. Furthermore, GPs are only part of the solution in terms of addressing alcohol consumption. The services available in the broader health care system and Government alcohol related policy needs to further support GPs and patients.

Age and performance at fledging are a cause and consequence of juvenile mortality between life stages.

Should they stay or should they leave? The age at which young transition between life stages, such as living in a nest versus leaving it, differs among species and the reasons why are unclear. We show that offspring of songbird species that leave the nest at a younger age have less developed wings that cause poorer flight performance and greater mortality after fledging. Experimentally delayed fledging verified that older age and better developed wings provide benefits of reduced juvenile mortality. Young are differentially constrained in the age that they can stay in the nest and enjoy these fitness benefits because of differences among species in opposing predation costs while in the nest. This tension between mortality in versus outside of the nest influences offspring traits and performance and creates an unrecognized conflict between parents and offspring that determines the optimal age to fledge.

Learning from patients: trainers' use of narratives for learning and teaching.

BACKGROUND: There is a growing interest in how doctors learn from narratives about individual cases, reflected, for example, in the use of e-portfolios. AIM: This study aimed to evaluate how GP trainers conceptualised 'learning from patients', and what use they currently made of narrative recounts in training. DESIGN & SETTING: Thematic analysis (TA) and corpus-linguistic (CL) analysis, with data collected from a convenience sample of trainers in the UK, Ireland, and Spain. METHOD: GP trainers in the three settings were contacted, and volunteers recruited (22 in UK, 24 in Ireland, and 16 in Spain). Volunteers were interviewed and asked to offer a narrative about 'a patient you learned from' and whether they used narratives as a training device. RESULTS: There were no differences between settings. Trainers described an engaged and personal relationship with patients. They described learning about themselves, the human condition, and about how to live and die well. Their narratives were structured in various ways. At times, they led to precise conclusions: at times, they were perceived as meaningful, but resisting analysis. As regards teaching through narrative, it was reported as commonly used, but present practice appears ad hoc rather than planned. DISCUSSION: The lack of difference between settings suggests a degree of commonality about how trainers perceive learning and teaching in the areas explored, but cannot be generalised further. The level of personal engagement was more than anticipated, and suggests the label 'doctor-patient relationship', as the term is used, may not be adequate to describe the nature of some interactions.

Delayed Presentation of a Cervical Spinal Epidural Abscess of Dental Origin after a Fall in an Elderly Patient.

Spinal epidural abscesses are an uncommon cause of spinal cord injury but, depending on the size and presence of neurological deficits, urgent neurosurgical intervention may be required. We present a unique case of a patient presenting with a spinal epidural collection several days after a fall. While a spinal epidural hematoma was suspected based on the patient's history and MRI findings, a spinal epidural abscess was found during surgery. The patient underwent laminectomy and instrumented fusion with successful treatment of her infection.

Analysis of Factors Contributing to Infections After Cranioplasty: A Single-Institution Retrospective Chart Review.

OBJECTIVE: Cranioplasty is one of the most common neurosurgical procedures, yet has one of the greatest rates of infection among cranial operations. Although studies have reported on cranioplasty complications, it is unclear what factors contribute to the high rate of infection. This study aims to determine which patient characteristics and operative factors lead to postcranioplasty infections. METHODS: This was a retrospective chart review of 186 patients. Factors analyzed included sex, reason for cranioplasty, type of infection, medical comorbidities, and surgical factors. RESULTS: The overall infection rate was 24%. Skin flora was the most common pathogen. Wound dehiscence and presence of a postoperative fluid collection were associated significantly with a greater rate of infection (P < 0.001), whereas the use of autologous bone flap and a state of immunosuppression trended toward statistical significance (P = 0.075 and P = 0.089, respectively). Male sex, history of previous infection, history of craniectomy for trauma, cranioplasty size, and time to cranioplasty were not found to be significant factors related to cranioplasty infection. CONCLUSIONS: Although wound dehiscence and postoperative fluid collections were associated significantly with infection in this study, the number in each sample size was small, and further studies with a larger number of patients in each subgroup is necessary to validate our findings.

Combined Transzygomatic and Pterional Approach for Resection of a Dermoid Cyst of the Foreman Ovale.

Dermoid cysts are rare, benign intracranial lesions commonly located in the posterior fossa. We describe a uniquely located dermoid cyst in the foreman ovale resected via a combined pterional and transzygomatic approach.

Mild exercise reduces cerebral vasospasm after aneurysm subarachnoid hemorrhage: a retrospective clinical study and correlation with laboratory investigation.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) is a leading cause of death and disability and is often complicated by cerebral vasospasm (CV). Conventional management to prevent CV includes bedrest; however, inactivity places the patient at risk for nonneurological complications. We investigated the effect of mild exercise after SAH in clinical and laboratory settings. METHODS: Clinical: Data from 80 patients with SAH were analyzed retrospectively. After aneurysms were secured, physical therapy was initiated as tolerated. CV and complications were compared by the timing of active physical therapy. Laboratory: 18 Rodents were divided into three groups: (1) control, (2) SAH without exercise, and (3) SAH plus mild exercise. On day 5, brainstems were removed and analyzed for the injury marker inducible nitric oxide synthase (iNOS). RESULTS: Clinical: Mild exercise before day 4 significantly lowered the incidence of symptomatic CV compared with the nonexercised group. There was no difference in the incidence of additional complications based upon exercise. Laboratory: Staining for iNOS was significantly higher in the SAH group than the control group, but there was no difference between exercised and nonexercised SAH groups, confirming that exercise did not promote neuronal injury. CONCLUSION: Early mobilization significantly reduced clinical CV. The relationship should be studied further in a prospective trial with defined exercise regimens.

Time-dependent changes in cerebrospinal fluid metal ions following aneurysm subarachnoid hemorrhage and their association with cerebral vasospasm.

Aneurysm subarachnoid hemorrhage affects 10 in 100,000 people annually, 40 % of whom will develop neurological deficits from ischemic stroke caused by cerebral vasospasm. Currently, the underlying mechanisms are uncertain. Metal ions are important modulators of neuronal electrophysiological conduction and smooth muscle cell activity, thereby potentially contributing to vasospasm. We hypothesized that metal ion concentrations in the cerebrospinal fluid (CSF) after aneurysm rupture would change over time and be associated with vasospasm. To test this hypothesis, for 21 days, we collected CSF from patients with aneurysmal rupture and subjected it to spectrometry to detect metals. A repeated measures analysis was performed to analyze concentration changes over time. Six of the seven patients with aneurysmal rupture experienced vasospasm, all resolving by day 14. Changes in Fe²âº and Zn²âº concentrations in the CSF paralleled the incidence of vasospasm in this study population. Na²âº, Ca²âº, Mg²âº, and Cu²âº concentrations exhibited no statistically significant changes over time. In conclusion, Fe²âº concentration in the CSF was significantly elevated during days 7-10, whereas Zn²âº concentrations spiked shortly thereafter, during days 11-14. This suggests that Fe²âº may be related to the induction of vasospasm and Zn²âº may be a marker of early brain injury secondary to ischemic injury and inflammation.

Laser induced thermal therapy (LITT) for pediatric brain tumors: case-based review.

Integration of Laser induced thermal therapy (LITT) to magnetic resonance imaging (MRI) have created new options for treating surgically challenging tumors in locations that would otherwise have represented an intrinsic comorbidity by the approach itself. As new applications and variations of the use are discussed, we present a case-based review of the history, development, and subsequent updates of minimally invasive MRI-guided laser interstitial thermal therapy (MRgLITT) ablation in pediatric brain tumors.

A low mortality rat model to assess delayed cerebral vasospasm after experimental subarachnoid hemorrhage.

OBJECTIVE: To characterize and establish a reproducible model that demonstrates delayed cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) in rats, in order to identify the initiating events, pathophysiological changes and potential targets for treatment. METHODS: Twenty-eight male Sprague-Dawley rats (250 - 300 g) were arbitrarily assigned to one of two groups - SAH or saline control. Rat subarachnoid hemorrhage in the SAH group (n=15) was induced by double injection of autologous blood, 48 hr apart, into the cisterna magna. Similarly, normal saline (n=13) was injected into the cisterna magna of the saline control group. Rats were sacrificed on day five after the second blood injection and the brains were preserved for histological analysis. The degree of vasospasm was measured using sections of the basilar artery, by measuring the internal luminal cross sectional area using NIH Image-J software. The significance was tested using Tukey/Kramer's statistical analysis. RESULTS: After analysis of histological sections, basilar artery luminal cross sectional area were smaller in the SAH than in the saline group, consistent with cerebral vasospasm in the former group. In the SAH group, basilar artery internal area (.056 µm ± 3) were significantly smaller from vasospasm five days after the second blood injection (seven days after the initial blood injection), compared to the saline control group with internal area (.069 ± 3; p=0.004). There were no mortalities from cerebral vasospasm. CONCLUSION: The rat double SAH model induces a mild, survivable, basilar artery vasospasm that can be used to study the pathophysiological mechanisms of cerebral vasospasm in a small animal model. A low and acceptable mortality rate is a significant criterion to be satisfied for an ideal SAH animal model so that the mechanisms of vasospasm can be elucidated. Further modifications of the model can be made to adjust for increased severity of vasospasm and neurological exams.

Dealing with uncertainty in general practice: an essential skill for the general practitioner.

Many patients attending general practice do not have an obvious diagnosis at presentation. Skills to deal with uncertainty are particularly important in general practice as undifferentiated and unorganised problems are a common challenge for general practitioners (GPs). This paper describes the management of uncertainty as an essential skill which should be included in educational programmes for both trainee and established GPs. Philosophers, psychologists and sociologists use different approaches to the conceptualisation of managing uncertainty. The literature on dealing with uncertainty focuses largely on identifying relevant evidence and decision making. Existing models of the consultation should be improved in order to understand consultations involving uncertainty. An alternative approach focusing on shared decision making and understanding the consultation from the patient's perspective is suggested. A good doctor-patient relationship is vital, creating trust and mutual respect, developed over time with good communication skills. Evidence-based medicine should be used, including discussion of probabilities where available. Trainers need to be aware of their own use of heuristics as they act as role models for trainees. Expression of feelings by trainees should be encouraged and acknowledged by trainers as a useful tool in dealing with uncertainty. Skills to deal with uncertainty should be regarded as quality improvement tools and included in educational programmes involving both trainee and established GPs.

Heartlift patients? An interview-based study of GP trainers and the impact of 'patients they like'.

BACKGROUND: The concept of the 'heartsink patient' is well known and much used when talking about general practice. The opposite of this type of patient, however, has been little explored. OBJECTIVE: To identify patient characteristics valued by GPs. METHODS: Structured interview to collect narratives from GPs of individual patients, analysed qualitatively through thematic analysis and word frequency. SETTING: Primary Care in Ireland. PARTICIPANTS: GP trainers. MAIN OUTCOME MEASURES: Emergent themes from four lead questions: Tell me about a patient you like, Tell me about the patient's personality, What have you learned about yourself as a GP?, What is different about being a GP as opposed to any other kind of doctor? In addition, a corpus linguistic analysis of word frequencies disclosed further themes, not identifiable on the surface of discourse. RESULTS: Ten themes were identified: GPs valued patients who were likeable, a challenge, involved them in negotiation of the doctor-patient relationship, were interesting or virtuous and had a positive effect. GPs valued their profession in that they were facilitators, gave and elicited loyalty, formed personal attachments and had a different perspective. CONCLUSIONS: 'Heartlift patients' may be a robust concept, to counterbalance heartsink patients. Data collected are suitable for training, and could help GPs enhance a sense of vocation.

Murine epidermal side population possesses unique angiogenic properties.

Total epidermal keratinocytes are a heterogeneous population of cells, including undifferentiated stem/progenitor cells (EpSPs) and their more differentiated progeny (Non-SP cells). Our previous in vivo data showed that EpSPs enhanced blood flow restoration when injected into an ischemic limb, whereas Non-SP cells had no significant effect on in vivo blood flow restoration. However, the cellular and molecular mechanisms of this observation remain largely unknown. Therefore, the aim of this study was to investigate the angiogenic properties of different epidermal subpopulations in vitro and the mechanism by which EpSPs enhanced blood flow in vivo. Using migration assay and capillary network formation, we show that EpSPs secrete higher levels of pro-angiogenic molecules compared to Non-SP cells, unsorted keratinocytes and fibroblasts in vitro. Secretion of vascular endothelial growth factor (VEGF) was detected at higher levels in EpSP conditioned medium than the medium conditioned by other epidermal subpopulations and fibroblasts. Also, RT-PCR analyses revealed a unique angiogenic gene profile for EpSPs. Finally, gene array data indicate significant changes in angiogenic gene expression six days after cell injection in murine ischemic limbs. Therefore, we conclude that EpSPs possess unique angiogenic properties and that these cells may be indirectly responsible for the angiogenic response previously observed in our ischemic limb model.

Distance learning: linking CME and quality improvement.

This paper describes the content and evaluation of a distance learning course in therapeutics for general practitioners. Following a pilot project, a comprehensive questionnaire was sent to the 49 participants who had completed the course in its first two years. There was an 80% response rate. Overall satisfaction levels and completion rates were high. Factors influencing the impact of distance learning in a general practice setting including structure, process and outcomes are discussed. Recommendations for further research are included.