Observer agreement regarding the necessity of retreatment of previously coiled recurrent cerebral aneurysms.

BACKGROUND AND PURPOSE: The decision regarding whether or not to retreat a previously treated aneurysm not only directly impacts patient care but also serves as a primary outcome measure in numerous, leading randomized controlled trials of modified coils. Our aim was to determine the degree of interobserver variability regarding the need and type of treatment for recurrent aneurysms following coil embolization. MATERIALS AND METHODS: Twenty-seven previously treated recurrent aneurysms were identified. Five independent readers rated each aneurysm on a 5-point scale: 1, definitely do not retreat; 2, probably do not retreat; 3, unsure; 4, probably retreat; and 5, definitely retreat. The readers noted, in grades 2-5, the type of retreatment preferred, including simple coiling, balloon- or stent-assist coiling, or surgical clipping. Intraobserver agreement κ was calculated. Retreatment recommendations were evaluated between observers by using a Wilcoxon signed rank comparison. Descriptive statistics were performed for categoric treatment-type comparisons. RESULTS: At least 2- or 3-point differences between 2 readers were present in 17 (63%) and 11 (41%) of 27 cases, respectively. The median κ was 0.27 (range, 0.04-0.43), which indicates fair agreement. Differences between readers varied, with readers 4 and 5 more often recommending retreatment compared with reviewers 1-3 (P < .05). Wide variation was noted in treatment approach, with recommendations for surgical clipping ranging from 2 (7%) to 18 (67%) of 27 cases between readers 1 and 5. CONCLUSIONS: The current study demonstrates substantial variability among observers not only in whether to retreat a recurrent aneurysm but also how to treat it. These findings suggest that patient management varies widely across treating physicians and also calls into question the use of "retreatment" as an objective end point in clinical trials.

Inter- and intraobserver agreement in CT characterization of nonaneurysmal perimesencephalic subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The perimesencephalic pattern of SAH as seen on unenhanced CT is associated with significantly better outcomes when compared to an aneurysmal pattern of SAH. The aim of this study was to determine the degree of inter- and intraoberver agreement for characterization of the NAPH as seen on unenhanced CT. MATERIALS AND METHODS: We retrospectively reviewed the CT scans of 37 patients with spontaneous SAH, all of whom had undergone CT within 24 hours of onset of headache symptoms. All patients had undergone conventional cerebral angiography to confirm or exclude aneurysms or other vascular pathology. All 37 cases were angiographically confirmed nonaneurysmal SAHs. Four readers with neuroradiology subspecialty training independently evaluated CT images to characterize the hemorrhage pattern as compatible with the well-described NAPH. Each reader performed a second reading session blinded to the initial readings. The first and second sets of readings were performed approximately 4 months apart. Inter- and intraobserver agreement for characterization of the NAPH was determined by using the kappa statistic. RESULTS: Of the 37 angiographically confirmed nonaneurysmal SAHs, there was unanimous agreement as to the hemorrhage pattern in 29 (78%) cases and disagreement in 8 (22%) cases. Overall, intraobserver agreement was good (kappa = 0.80). Interobserver agreement was also good (kappa = 0.79). CONCLUSIONS: Overall, inter- and intraobserver agreement for the NAPH was good. There was, however, a level of disagreement among observers, thus suggesting that clinicians should be cautious when deciding whether to pursue follow-up imaging.

Rescue retrieval of AngioGuard embolic capture system after failure of capture sheath retrieval in carotid angioplasty and stenting.

This report describes the cases of 2 patients with failed retrieval of an AngioGuard distal protection device after carotid stent placement with rescue retrieval by use of a vertebral catheter. An AngioGuard was deployed before carotid angioplasty and stent placement. Attempted removal of the device with the provided recapture sheath was unsuccessful. A 5F 120-cm vertebral catheter was used to recapture and remove the AngioGuard. This technique is a simple and readily available solution for the retrieval of failed removal of a protection device.

Coils in a nutshell: a review of coil physical properties.

Since its inception, endovascular coil technology has grown substantially as multiple manufacturers entered the market with an ever-increasing number of new products. Practitioners are now inundated with a choice of coils that vary on the basis of factors such as size, composition, stiffness, and detachment mechanism. The seasoned interventionalist had the benefit of evolving with this technology and, therefore, is likely to understand many of the practical nuances of coil development; for more junior practitioners, who did not experience the ongoing changes in technology, this review will provide a basic framework for the fundamentals of coil design.

But did you use HydroCoil? Perianeurysmal edema and hydrocephalus with bare platinum coils.

SUMMARY: Bioactive coils were developed to improve aneurysm packing and accelerate neointimal healing. Recent reports, however, have implicated these coils in the development of aseptic meningitis, perianeurysmal edema, and hydrocephalus. This report demonstrates that the same clinical phenomena can occur with the use of bare platinum coils.

Vascular compression as a potential cause of occipital neuralgia: a case report.

Vascular compression is a well-established cause of cranial nerve neuralgic syndromes. A unique case is presented that demonstrates that vascular compression may be a possible cause of occipital neuralgia. A 48-year-old woman with refractory left occipital neuralgia revealed on magnetic resonance imaging and computed tomographic imaging of the upper cervical spine an atypically low loop of the left posterior inferior cerebellar artery (PICA), clearly indenting the dorsal upper cervical roots. During surgery, the PICA loop was interdigitated with the C1 and C2 dorsal roots. Microvascular decompression alone has never been described for occipital neuralgia, despite the strong clinical correlation in this case. Therefore, both sectioning the dorsal roots of C2 and microvascular decompression of the PICA loop were performed. Postoperatively, the patient experienced complete cure of her neuralgia. Vascular compression as a cause of refractory occipital neuralgia should be considered when assessing surgical options.

Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas.

This report describes a series of patients for whom dural arteriovenous fistulae (DAVFs) of the cavernous sinus were successfully embolized using a percutaneous, transorbital technique to directly cannulate the cavernous sinus. A vascular access needle and catheter are percutaneously advanced along the inferolateral aspect of the orbit to access the cavernous sinus via the superior orbital fissure. Safe and effective embolization is achieved without the need for a surgical cut-down.

Systematic study of d-wave superconductivity in the 2D repulsive Hubbard model.

The cluster size dependence of superconductivity in the conventional two-dimensional Hubbard model, commonly believed to describe high-temperature superconductors, is systematically studied using the dynamical cluster approximation and quantum Monte Carlo simulations as a cluster solver. Because of the nonlocality of the d-wave superconducting order parameter, the results on small clusters show large size and geometry effects. In large enough clusters, the results are independent of the cluster size and display a finite temperature instability to d-wave superconductivity.

Reduction in atrial defibrillation threshold by a single linear ablation lesion.

INTRODUCTION: This study investigated a hybrid approach to reduce the atrial defibrillation threshold (ADFT) by determining the effect of a single linear radiofrequency ablation (RFA) lesion on both the ADFT and activation patterns during atrial fibrillation (AF). METHODS AND RESULTS: In 18 open chest sheep (45 to 57 kg), coil defibrillation electrodes were placed in a superior vena cava/right ventricular configuration. AF was induced by burst pacing and maintained with acetyl beta-methylcholine (2 to 42 microL/min). ADFTs were obtained before and after a linear RFA lesion was created in the left atrium (LAL; n = 6), right atrium (RAL; n = 6), or neither atrium as a control (n = 6). In animals receiving an LAL, a 504-unipolar-electrode plaque was sutured to the LA. For animals receiving an RAL, two 504-electrode plaques were placed, one each on the LA and RA. From each plaque, activations were recorded before and after ADFT shocks, and organizational characteristics of activations were analyzed using algorithms that track individual wavefronts. In sham-treated controls, the ADFT did not change. In contrast, LAL reduced ADFT energy 29%, from 4.5 +/- 2.3 J to 3.2 +/- 2.0 J (P < 0.05). RAL reduced ADFT energy 25%, from 2.0 +/- 0.9 J to 1.5 +/- 0.7 J (P < 0.05). AF activation was substantially more organized after RFA than before RFA for both the RAL- and LAL-treated animals. CONCLUSION: A single RFA lesion in either the RA or LA reduces the ADFT in this sheep model. This decrease is associated with an increase in fibrillatory organization.

Reproducible high efficiency gene transfer into Y79 retinoblastoma cells using adenofection.

Several photoreceptor-specific genes are actively transcribed in Y79 retinoblastoma (Rb) cells, making this cell line potentially useful for the study of photoreceptor metabolism. The utility of these cells is limited because commonly used methods of gene transfer into Y79 cells are inefficient and lack reproducibility. In contrast, we found that adenovirus transduction yields high efficiency gene transfer, however, generation of recombinant adenovirus is lengthy and time consuming. Here, we show that adenofection, a method of coupling adenovirus to plasmid DNA for improved gene transfer, is efficient for gene delivery into Y79 cells. Recombinant adenovirus expressing bacterial lacZ was noncovalently complexed to GFP or luciferase reporter plasmids with polyethylenimine. Efficiency of plasmid gene delivery was determined by monitoring GFP fluorescence. For comparison, calcium phosphate-mediated or cationic lipid transfection was performed in Y79 and HEK293 cells using standard protocols. The adenofection protocol yielded significantly higher efficiencies in Y79 cells than that obtained in these cells with calcium phosphate or cationic lipids. This method will facilitate any experiment requiring reproducible high-level gene transfer. Here, we show that adenofection can be used to analyze activity of the rod photoreceptor PDE6A gene promoter.

Pacing after shocks stronger than the upper limit of vulnerability: impact on fibrillation induction.

BACKGROUND: After upper-limit-of-vulnerability (ULV) shocks of the same strength and coupling interval (CI) during the T wave, (1) the epicardial activation pattern (EAP) for the first postshock cycle is indistinguishable between shocks that do (VF) and do not (NoVF) induce ventricular fibrillation (VF) and (2) >/=3 cycles in rapid succession always occur during VF but not during NoVF episodes. To study the role of these rapid cycles, rapid pacing was performed after a shock stronger than the ULV that by itself did not induce rapid cycles and VF. METHODS AND RESULTS: A 504-electrode sock was sutured to the heart in 6 pigs to map EAPs. The S2 shock strength and S1-S2 CI at the ULV were determined by T-wave scanning with an up/down protocol. Ten shocks 50 to 100 V above the ULV (aULV) were delivered at the same S1-S2 CI to confirm that VF was not induced. Then, the postshock interval after aULV shocks was scanned with an S3 pacing stimulus from the LV apex until the shortest S2-S3 CI that captured was reached. This was repeated for S4, S5, etc, until VF was induced. To induce VF, 3 pacing stimuli (S3-S5) with progressively shorter CIs were required; S3 or S3, S4 never induced VF. After cycle S5, which induced VF, 2 EAP types occurred: focal (74%) and reentrant (26%). CONCLUSIONS: At least 3 cycles with short CIs are necessary for VF induction after aULV shocks. Cycles S3-S4 may create the substrate for cycle S5 to initiate VF.

Predicting the relative efficacy of shock waveforms for transthoracic defibrillation in dogs.

STUDY OBJECTIVE: Previous work has shown that a passive membrane model using a parallel resistor-capacitor circuit is capable of predicting optimal waveforms for transvenous defibrillation. This study tested the ability of that model to predict optimal waveforms for transthoracic defibrillation. METHODS: This study was divided into 3 parts, each of which determined transthoracic defibrillation thresholds (DFTs) in 6 dogs for several different waveform shapes and durations. For each part, strength-duration relationships were determined from both experimental and model data and then compared with test model predictions. Part 1 DFTs were determined at various durations for 3 different monophasic waveforms-the ascending ramp, descending ramp, and square waveform. Part 2 DFTs were determined for 3 biphasic waveforms. Phase 1 was a 30-ms ascending ramp, and phase 2 was an ascending ramp, a descending ramp, or a square waveform. Part 3 DFTs were determined for 3 biphasic waveforms with very short second-phase durations. Phase 1 was a 30-ms ascending ramp, and phase 2 was a descending ramp. RESULTS: For part 1, the model was able to predict the relative defibrillation efficacy of the 3 monophasic waveforms ( P < .05). For parts 2 and 3, the model was able to predict the biphasic waveforms with the lowest DFTs. These predictions were based on the criterion that the model response at the end of the second phase should return to or slightly pass the model response value at the beginning of the first phase. CONCLUSION: The resistor-capacitor model successfully predicted the relative defibrillation efficacy of several different waveforms delivered transthoracically.

Comparison of pentastarch and Hartmann's solution for volume preloading in spinal anaesthesia for elective caesarean section.

We studied 160 patients undergoing elective Caesarean section under spinal anaesthesia who received a preloading volume of 15 ml kg-1 of 10% pentastarch in 0.9% saline, or Hartmann's solution, in a prospective, randomized, double-blind study. We compared the incidence of spinal-induced hypotension in each group. Hypotension was defined as a decrease in systolic arterial pressure to less than 70% of baseline values or < or = 90 mm Hg, whichever was the greater. The groups were comparable in physical characteristics and there was no serious morbidity. Fetal outcome was similar in both groups. Significantly more patients in the Hartmann's group (n = 38, 47.5%) developed hypotension than in the pentastarch group (n = 10, 12.5%) (P < 0.0001). Linear regression analysis showed that the only significant variable was type of fluid used. Blood glucose concentrations were not related to the presence of hypotension. We conclude that starches may be suitable for preloading in Caesarean section under spinal anaesthesia and provide an alternative to the aggressive use of vasoconstrictors.

The effects of managed care on the quality of dental hygiene care.

PURPOSE: This study examined whether patients insured by a managed dental care plan receive lower quality dental hygiene care than those not enrolled in a managed dental care plan. METHODS: Questionnaire data were gathered from 193 dental hygienists in the Chicago, Illinois area. Managed care was measured by a questionnaire item that assessed the proportion of managed care patients treated by the subject; quality of dental hygiene care was measured by items that assessed the extent to which the subject performed each of 23 dental hygiene tasks. RESULTS: A factor analysis of the 23 items assessing the quality of dental hygiene care indicated four meaningful factors named: periodontal procedures, appointment time, visual examinations, and oral examinations. Measures based on these factors were the dependent variables in regression analysis that included managed care as the primary independent variable and demographic characteristics of the subjects and their practices as control variables. Managed care had a significant (p < .05) negative relationship with appointment time, but did not have a significant relationship with periodontal procedures, visual examinations, or oral examinations. CONCLUSION: This study suggests that managed dental care program patients may have inadequate appointment time with a dental hygienist, which may affect whether they receive important services, such as oral health education. Dental hygienists in managed-care environments should be certain they are making effective use of the scheduled appointment time and procedures to ensure managed-care patients receive adequate time for dental hygiene care.

Myocardial discontinuities: a substrate for producing virtual electrodes that directly excite the myocardium by shocks.

BACKGROUND: Theoretical models suggest that an electrical stimulus causes regions of depolarization and hyperpolarization on either side of a myocardial discontinuity. This study determined experimentally whether an artificial discontinuity gives rise to an activation front in response to an electrical stimulus, consistent with the creation of such polarized regions. METHODS AND RESULTS: After a thoracotomy in six dogs, a 504-unipolar-electrode plaque was sutured to the right ventricular epicardium to map activations. From a line electrode parallel to one side of the plaque, 10 S1 stimuli were delivered, followed by S2 and S3 stimuli (S1S1, S1S2, S2S3 interval=300 ms). S1 and S3 stimuli were 25 mA; 5-ms S2 stimuli of both polarities were initially 25 mA and increased in 25 mA increments. The plaque was removed, and a transmural incision was made through the ventricular wall in the middle of the mapped region and sutured closed. The plaque was replaced and the stimulation protocol repeated. Before the incision, S2 stimuli directly activated tissue only near the stimulation site. An activation front arose at the border of the directly activated region and propagated across the plaque. As the S2 stimulus strength was increased, the size of the directly activated region increased. After the incision, sufficiently large S2 stimuli caused direct activation of tissue adjacent to the transmural incision as well as at the stimulation site. Activation fronts that arose adjacent to the transmural incision either propagated proximally toward the stimulation site and collided with the activation front originating from the stimulation wire or propagated distally away from the incision. Minimum S2 stimulus strengths activating areas adjacent to the incision were only 45+/-14% (cathode) and 39+/-18% (anode) of the strengths required to directly activate the same area before the incision was formed (P<.05). CONCLUSIONS: Myocardial discontinuities can give rise to activation fronts after a stimulus, suggesting the presence of polarized regions adjacent to the discontinuity.

Effect of alpha-tomatine and tomatidine on membrane potential of frog embryos and active transport of ions in frog skin.

alpha-Tomatine, a glycoside in which four carbohydrate residues are attached to the 3-OH group of the aglycone tomatidine, occurs naturally in tomatoes (Lycopersicon esculentum). The glycoalkaloid is reported to be involved in host-plant resistance against phytopathogens and to have a variety of pharmacological and toxicological properties in animals and humans. As part of an effort designed to establish the mechanism of action of glycoalkaloids in cells, frog embryos and frog skin were exposed to varying concentrations of alpha-tomatine and tomatidine. alpha-Tomatine increased the fluorescence-measured membrane permeability of frog embryos by about 600% compared with control values; the corresponding value for tomatidine was about 150%. alpha-Tomatine also diminished sodium-active transport in frog skin by about 16% compared with control values, as estimated from the change in the interstitial short-circuit current. Tomatidine had no effect on frog skin. As these findings complement similar results with glycoalkaloids from potatoes and eggplants, the fundamental mechanism governing their action both against fungi, insects and other phytopathogens and in animal and human cells may be disruption of cell membranes and changes in ion fluxes and interstitial currents of the membranes. The described methodologies should make it possible to define the relative potencies of both adverse and beneficial effects of glycoalkaloids and metabolites in cell membranes without the use of animals.

Evaluating nurse turnover: comparing attitude surveys and exit interviews.

High turnover rates among hospital nurses demand rigorous and valid processes of research to determine the reasons motivating such attrition. In most hospitals, the exit interview often provides the only relevant data. The case study reported here examines the relative effectiveness of exit interviews and an employee attitude survey in generating data that are useful in managing nurse retention. The conclusion reached is that the attitude survey generates more data and higher-quality data. Further, the study shows that the use of open-ended questions can provide useful information and probably should be the starting point in developing or supplementing an attitude survey for nurses. Recommendations for improving the usefulness and validity of nurse attitude surveys and exit interviews in managing nurse retention are provided.