Monitoring cerebral autoregulation after head injury. Which component of transcranial Doppler flow velocity is optimal?

Background

Cerebral autoregulation assessed using transcranial Doppler (TCD) mean flow velocity (FV) in response to various physiological challenges is predictive of outcome after traumatic brain injury (TBI). Systolic and diastolic FV have been explored in other diseases. This study aims to evaluate the systolic, mean and diastolic FV for monitoring autoregulation and predicting outcome after TBI.

Methods

300 head-injured patients with blood pressure (ABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), and FV recordings were studied. Autoregulation was calculated as a correlation of slow changes in diastolic, mean and systolic components of FV with CPP (Dx, Mx, Sx, respectively) and ABP (Dxa, Mxa, Sxa, respectively) from 30 consecutive 10?s averaged values. The relationship with age, severity of injury, and dichotomized 6?months outcome was examined.

Results

Association with outcome was significant for Mx and Sx. For favorable/unfavorable and death/survival outcomes Sx showed the strongest association (F?=?20.11; P?=?0.00001 and F?=?13.10; P?=?0.0003, respectively). Similarly, indices derived from ABP demonstrated the highest discriminatory value when systolic FV was used (F?=?12.49; P?=?0.0005 and F?=?5.32; P?=?0.02, respectively). Indices derived from diastolic FV demonstrated significant differences (when calculated using CPP) only when comparing between fatal and non-fatal outcome.

Conclusions

Systolic flow indices (Sx and Sxa) demonstrated a stronger association with outcome than the mean flow indices (Mx and Mxa), irrespective of whether CPP or ABP was used for calculation.     

Retrospective Evaluation of Nicardipine Versus Labetalol for Blood Pressure Control in Aneurysmal Subarachnoid Hemorrhage

Background

American Heart Association/American Stroke Association guidelines for management of aneurysmal subarachnoid hemorrhage (aSAH) recommend blood pressure (BP) control, utilizing labetalol or nicardipine, but do not differentiate efficacy between the two agents. The purpose of this retrospective study was to compare BP control between labetalol and nicardipine in patients following aSAH.

Methods

Consecutive adult patients admitted to the ICU with a diagnosis of SAH treated with labetalol or nicardipine were retrospectively identified. Patients were included if they received more than one bolus dose of labetalol or a nicardipine infusion for greater than 3?h. Patients were excluded if they were <18?years of age, experiencing an ICH, acute ischemic stroke or a TIA. Patients were stratified into two groups (labetalol vs. nicardipine) and data was collected for 72?h. The outcomes compared were time within goal mean arterial pressure (MAP), average MAP/patient, MAP variability, initial response to therapy, and treatment failure. Goal MAP was defined as 70?C110?mmHg.

Results

There were 103 patients evaluated (labetalol n?=?43; nicardipine n?=?60). Demographics and baseline MAP were similar between the two groups. Nicardipine was associated with a longer time within goal MAP (78?±?24 vs. 58?±?36?%, p?=?0.001) and lower average MAP/patient (93?±?11 vs. 106?±?12?mmHg, p?p?=?0.137). Nicardipine led to a more rapid response to therapy (F?=?8.1; p?=?0.005) and fewer treatment failures (0 vs. 28?%, p?Conclusions Our study showed nicardipine to be associated with superior BP control versus labetalol in aSAH.     

A Continuous Correlation Between Intracranial Pressure and Cerebral Blood Flow Velocity Reflects Cerebral Autoregulation Impairment During Intracranial Pressure Plateau Waves

Background

In the healthy brain, small oscillations in intracranial pressure (ICP) occur synchronously with those in cerebral blood volume (CBV), cerebrovascular resistance, and consequently cerebral blood flow velocity (CBFV). Previous work has shown that the usual synchrony between ICP and CBFV is lost during intracranial hypertension. Moreover, a continuously computed measure of the ICP/CBFV association (Fix index) was a more sensitive predictor of outcome after traumatic brain injury (TBI) than a measure of autoregulation (Mx index). In the current study we computed Fix during ICP plateau waves, to observe its behavior during a defined period of cerebrovascular vasodilatation.

Methods

Twenty-nine recordings of arterial blood pressure (ABP), ICP, and CBFV taken during ICP plateau waves were obtained from the Addenbrooke’s hospital TBI database. Raw data was filtered prior to computing Mx and Fix according to previously published methods. Analyzed data was segmented into three phases (pre, peak, and post), and a median value of each parameter was stored for analysis.

Results

ICP increased from a median of 22–44 mmHg before falling to 19 mmHg. Both Mx and Fix responded to the increase in ICP, with Mx trending toward +1, while Fix trended toward ?1. Mx and Fix correlated significantly (Spearman’s R = ?0.89, p < 0.000001), however, Fix spanned a greater range than Mx. A plot of Mx and Fix against CPP showed a plateau (Mx) or trough (Fix) consistent with a zone of “optimal CPP”.

Conclusions

The Fix index can identify complete loss of cerebral autoregulation as the point at which the normally positive CBF/CBV correlation is reversed. Both CBF and CBV can be monitored noninvasively using near-infrared spectroscopy (NIRS), suggesting that a noninvasive method of monitoring autoregulation using only NIRS may be possible.     

Continuous Monitoring of Cerebrovascular Reactivity Using Pulse Waveform of Intracranial Pressure

Background

Guidelines for the management of traumatic brain injury (TBI) call for the development of accurate methods for assessment of the relationship between cerebral perfusion pressure (CPP) and cerebral autoregulation and to determine the influence of quantitative indices of pressure autoregulation on outcome. We investigated the relationship between slow fluctuations of arterial blood pressure (ABP) and intracranial pressure (ICP) pulse amplitude (an index called PAx) using a moving correlation technique to reflect the state of cerebral vasoreactivity and compared it to the index of pressure reactivity (PRx) as a moving correlation coefficient between averaged values of ABP and ICP.

Methods

A retrospective analysis of prospective 327 TBI patients (admitted on neurocritical care unit of a university hospital in the period 2003?C2009) with continuous ABP and ICP monitoring.

Results

PAx was worse in patients who died compared to those who survived (?0.04?±?0.15 vs. ?0.16?±?0.15, ??²?=?28, p?2?=?6, p?=?0.01).

Conclusions

PAx is a new modified index of cerebrovascular reactivity which performs equally well as established PRx in long-term monitoring in severe TBI patients, but importantly is potentially more robust at lower values of ICP. In view of establishing an autoregulation-oriented CPP therapy, continuous determination of PAx is feasible but its value has to be evaluated in a prospective controlled trail.     

Near-Infrared Spectroscopy for Evaluation of Cerebral Autoregulation During Orthotopic Liver Transplantation

Introduction  

The present study evaluated whether frontal lobe cerebral oxygenation (S_cO₂), as assessed by near-infrared spectroscopy (NIRS), can detect cerebral autoregulation in patients undergoing orthotopic liver transplantation.     

MSNA during prolonged post-faint hypotension

Background

Following tilt-induced syncope, blood pressure usually recovers rapidly after tilt back to the horizontal position. However, in some patients, hemodynamic recovery is delayed, a condition recently termed “prolonged post-faint hypotension” (PPFH). The mechanism is thought to be mediated by increased vagal outflow rather than exaggerated peripheral vasodilatation and sympathetic withdrawal. To date, no muscle sympathetic nerve activity (MSNA) recordings have been reported in this condition, so we aimed to confirm that neither vasodilatation nor MSNA withdrawal was responsible.

Objectives

To retrospectively select patients with satisfactory recordings of continuous BP and MSNA during tilt-induced syncope. To compare hemodynamic and MSNA profiles in patients with PPFH to patients with normal recovery (NR) after tilt-back.

Methods

All patients were studied in Christchurch, New Zealand, between 1998 and 2008 using continuous arterial BP monitoring, and microneurographic recordings of MSNA from the right leg. Only patients with satisfactory BP and MSNA data throughout baseline, head-up tilt and presyncope were selected. Stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were derived using Modelflow. After baseline measurements, patients were tilted to the head-up 60° position and given GTN spray if asymptomatic after 20?min. Following the onset of presyncope, patients were tilted slowly back to the horizontal. PPFH was defined as systolic BP <85?mmHg for at least 2?min after tilt-back. Measurements were averaged at baseline, early tilt, presyncope, early and late recovery. Within-group comparisons were made between baseline and all other time points. Between-group comparisons were made over all time points.

Results

Patients with PPFH (7 males, age 46?±?5?years, n?=?8) and with NR (8 males, age 47?±?6 years, n?=?8) were selected. Presyncope was provoked by GTN in 4/8 patients in each group. In both groups, MAP remained below baseline during early and late recovery: PPFH 84?±?5 versus 51?±?5 and 64?±?5?mmHg (p?=?0.001, p?=?0.001); NR 104?±?5 versus 83?±?5 and 93?±?5?mmHg (p?=?0.001, p?=?0.03). However, MAP and HR were lower in the PPFH group (p?=?0.004, p?=?0.023). During early recovery, CO remained below baseline only in the PPFH group (p?=?0.001), whereas TPR remained constant in both groups. In both groups, all MSNA indices tended to remain above baseline levels during early and late recovery. PPFH 25?±?2 increased to 31?±?6 and 29?±?4 bursts/min (p?=?0.09, 0.02); NR 23?±?3 increased to 33?±?3 and 34?±?3 bursts/min (p?=?0.06, 0.01).

Conclusions

PPFH does not appear to be mediated by exaggerated vasodilatation or sympathetic withdrawal. Delayed recovery of cardiac output by increased vagal outflow is a more likely mechanism.     

The Effect of Transfer and Hospital Volume in Subarachnoid Hemorrhage Patients

Introduction

Prompt management of aneurysmal subarachnoid hemorrhage (SAH) is critical. Literature is inconclusive regarding outcomes for patients directly admitted to specialized centers versus transferred from lower-volume hospitals. Providers are often unclear about the safety of transferring critical patients. This study evaluated the ??transfer effect?? in a large sample of aneurysmal SAH patients undergoing treatment.

Methods

Using Nationwide Inpatient Sample 2002?C2007 data, we analyzed outcomes of SAH patients treated with coil or clip procedures. Analyses studied the effect of direct-admit versus transfer admission on mortality, discharge disposition, complications, length of stay (LOS), and total charges.

Results

Of 47,114 patients, 31,711 (67.3?%) were direct-admits and 15,403 (32.7?%) were transfers. More transfer patients were coiled than direct-admits (45.3 vs. 33.7?%, p?<?0.0001) and fewer underwent ventriculostomy (26.6 vs. 31.5?%, p?=?0.003). Older age (OR 1.2, p?<?0.0001), higher disease severity (OR 1.4, p?<?0.0001), lower volume (OR 1.5, p?<?0.0001), and ventriculostomy (OR 2.1, p?<?0.0001) increased mortality and predicted non-routine discharge, complications, LOS, and charges. Transfer patients had similar mortality (OR 0.9, p?=?0.13) and complications (OR 0.9, p?=?0.22) as direct-admits, but incurred higher non-routine discharge (OR 1.3, p?=?0.002). Analysis of grade V patients demonstrated similar outcomes between direct-admits and transfers; however, charges for treating transfer patients were notably higher ($401,386 vs. $242,774, p?=?0.03).

Conclusion

Patients treated in the lowest volume hospitals were 1.6 times more likely to die than those treated at the highest quintile hospitals. Among the critically ill grade V patients, transfer to higher-volume specialized centers did not increase the likelihood of a poor prognosis.     

Frequency of Eye Deviation in Stroke and Non-stroke Patients Undergoing Head CT

Background and Purpose

Although conjugate eye deviation (CED) on head CT has been described in patients with acute stroke, the incidence in other patient groups remains unknown. The aim of this study was to determine the frequency of eye deviation on head CT in non-stroke patients compared to patients with acute stroke symptoms.

Materials and Methods

Three groups of patients were identified retrospectively: emergency department (ED)/inpatients undergoing head CT for non-stroke symptoms (Group 1), stroke patients receiving intravenous tPA (Group 2), and stroke patients undergoing intra-arterial therapy (Group 3). The presence on head CT of CED, lone eye deviation (LED), and skew deviation (SD) and the angle of deviation were recorded. The NIHSS score was recorded for Groups 2 and 3.

Results

CED was present in 17 (14?%) of 120 Group 1 patients, 17 (36?%) of 47 Group 2 patients, and 28 (50?%) of 56 Group 3 patients (p?o (range 7?C36^o), 25^o (range 6?C67^o), and 27^o (range 11?C56^o), respectively (p?=?0.024). LED was seen in 42 (35?%) of Group 1, 7 (15?%) of Group 2, and 2 (4?%) of Group 3 patients (p?p?=?0.37). CED was associated with a higher National Institutes of Health Stroke Scale (NIHSS) score among stroke patients (p?=?0.0008).

Conclusion

CED is common in patients with acute stroke. Such deviation may be seen in non-stroke patients, but less commonly and with lesser degrees of deviation.     

Relationship of Vascular Wall Tension and Autoregulation Following Traumatic Brain Injury

Background

The vascular wall tension (WT) of small cerebral vessels can be quantitatively estimated through the concept of critical closing pressure (CrCP), which denotes the lower limit of arterial blood pressure (ABP), below which small cerebral arterial vessels collapse and blood flow ceases. WT can be expressed as the difference between CrCP and intracranial pressure (ICP) and represent active vasomotor tone. In this study, we investigated the association of WT and CrCP with autoregulation and outcome of a large group of patients after traumatic brain injury (TBI).

Methods

We retrospectively analysed recordings of ABP, ICP and transcranial Doppler (TCD) blood flow velocity from 280 TBI patients (median age: 29 years; interquartile range: 20–43). CrCP and WT were calculated using the cerebrovascular impedance methodology. Autoregulation was assessed based on TCD-based indices, Mx and ARI.

Results

Low values of WT were found to be associated with an impaired autoregulatory capacity, signified by its correlation to FV-based indices Mx (R = ?0.138; p = 0.021) and ARI (R = 0.118; p = 0.048). No relationship could be established between CrCP and any of the autoregulatory indices. Neither CrCP nor WT was found to correlate with outcome.

Conclusions

Impaired autoregulation was found to be associated with a lower WT supporting the role of vasoparalysis in the loss of autoregulatory capacity. In contrast, no links between CrCP and autoregulation could be identified.     

Non-adherence to Immunosuppressive Medications in Kidney Transplantation: Intent Vs. Forgetfulness and Clinical Markers of Medication Intake

Background

Although adherence to immunosupressive medication after transplantation is important to maximize good clinical outcomes it remains suboptimal and not well-understood. The purpose of this study was to examine intentional and unintentional non-adherence to immunosuppression medication in kidney transplant patients.

Methods

A cross-sectional sample of N?=?218 patients [49.6?±?12.3?years] recruited in London, UK (1999?C2002) completed measures of medication beliefs, quality-of-life, depression, and transplantation-specific emotions. Adherence was measured with self-report and serial immunosuppressive assays.

Results

Intentional non-adherence was low (13.8?%) yet 62.4?% admitted unintentional non-adherence and 25.4?% had sub-target immunosuppressive levels. The risk of sub-target serum immunosuppressive levels was greater for patients admitting unintentional non-adherence (OR?=?8.4; p?=?0.004). Dialysis vintage, doubts about necessity, and lower worry about viability of graft explained R ²?=?16.1 to 36?% of self-report non-adherence. Depression was related only to intentional non-adherence.

Conclusions

Non-adherence is common in kidney transplantation. Efforts to increase adherence should be implemented by targeting necessity beliefs, monitoring depression, and promoting strategies to decrease forgetfulness.     

Identifying Risk Factors for Central Pontine and Extrapontine Myelinolysis After Liver Transplantation: A Case–Control Study

Background

Central pontine and extrapontine myelinolysis (CPEPM) is a rare but potentially fatal complication after orthotopic liver transplantation (OLT). The aim of this study was to identify risk factors for development of CPEPM after OLT and to assess patient outcome.

Methods

We reviewed the clinical data of 1,378 patients who underwent OLT between 1987 and 2009 in Geneva, Switzerland and Edmonton, Canada. Nineteen patients (1.4 %) developed CPEPM. We compared their characteristics with control patients, matched by age, gender, date of OLT, and MELD score.

Results

The 19 patients with CPEPM (7F, mean age 52.1 ± 2 years) had a mean MELD score of 26 ± 2.2. Before OLT, patients who develop CPEPM presented more frequently low (<130 mmol/l; p < 0.04) and very low (<125 mmol/l; p < 0.009) sodium than controls. In patients developing CPEPM, the number of platelet units and fresh frozen plasma transfused during surgery was higher (p = 0.05 and 0.047), hemorrhagic complications were more frequent after OLT (p = 0.049), and variations of sodium before and after OLT were higher (p = 0.023). The association of >2 of these conditions were strongly associated with CPEPM (p = 0.00015). Mortality at 1 year of patients developing CPEPM was higher (63 vs. 13 %, p < 0.0001).

Conclusions

High MELD score patients undergoing OLT, receiving massive perfusions of Na-rich products, experiencing surgery-related hemorrhagic complication and important fluctuations of Na are at risk of developing CPEPM. Therefore careful monitoring of natremia in the perioperative period and use of water-free perfusion in case of massive blood-products transfusion are critical points of this patient management.     

Effect of Percutaneous Tracheostomy on Intracerebral Pressure and Perfusion Pressure in Patients with Acute Cerebral Dysfunction (TIP Trial): An Observational Study

Background

Bedside percutaneous tracheostomy (PT) is very commonly used for patients who require prolonged mechanical ventilation. The effect of tracheostomy on intracranial pressure (ICP) is currently a subject of controversy. The aim of our study is to clarify the relation between PT and its effect on ICP and cerebral perfusion pressure.

Methods

38 patients on our intensive care unit were included prospectively in an observational study. We examined mean values of HF, SpO₂, ICP, CPP, and MAP for changes over five different phases of the procedure using paired Mann?CWhitney U tests. A p value of <0.05 was considered significant. p values were Bonferroni corrected for multiple testing.

Results

PT was performed on 38 patients (f?=?19, m?=?19; mean?=?56?years). Median ICP before intervention was 9?mmHg. During positioning of the patient, ICP had risen to 14, during bronchoscopy to 16, and during tracheostomy to 18?mmHg, all being significantly higher than baseline level. Monitoring of MAP showed a significant increase to 101?mmHg only during tracheostomy. SpO₂ and HF did not show any significant changes. Mean duration of positioning, bronchoscopy and tracheostomy was 19, 10, and 17?min. 8 patients received osmotherapy due to a rise of ICP of more than 30?mmHg.

Conclusion

PT only leads to a significant rise of ICP during the procedure. Nevertheless, therapy of ICP is necessary in some patients. From our point of view, therefore, tracheostomy should only be performed under continuous monitoring of ICP and CPP in patients with severe cerebral dysfunctions and critically elevated ICP.     

Imidafenacin on bladder and cognitive function in neurologic OAB patients

Objective

To explore imidafenacin’s effects on bladder and cognitive function in neurologic overactive bladder (OAB) patients.

Methods

Sixty-two subjects (25 men, 37 women; mean age 70 years (25–86) with OAB due to neurologic diseases) were enrolled in the study. We conducted a urinary symptom survey and cognitive tests (MMSE, FAB, ADAS-cog) in all patients. We performed urodynamics in 35 patients and measured real-time near-infrared spectroscopy (NIRS)-urodynamics in eight patients before and after the administration of imidafenacin, an anticholinergic agent, for 3 months at 0.2 mg/day.

Results

Imidafenacin significantly ameliorated urinary urgency, nighttime urinary frequency, and quality of life index (p < 0.05). Three cognitive measures did not change significantly. Urodynamics showed increased bladder capacity (p < 0.05) but detrusor overactivity did not change significantly. NIRS showed that the subtraction of oxyhemoglobin between the start of filling and the first sensation increased in the bilateral prefrontal area but without statistical significance.

Conclusions

Imidafenacin ameliorated bladder sensation without cognitive worsening, with a trend of prefrontal activation. Regarding cognitive function, imidafenacin is safely used in OAB patients due to neurologic diseases.

Synopsis

In order to explore imidafenacin (anticholinergic agent)’s effects on bladder and brain function, we performed urinary questionnaire, cognitive tests, urodynamics and near-infrared spectroscopy (selected cases) in 62 overactive bladder (OAB) patients due to various neurologic diseases. As a result, imidafenacin ameliorated bladder sensation without cognitive worsening, with a trend of prefrontal activation. Imidafenacin seems safe in treating OAB patients due to neurologic diseases.     

Does Affective Valence During and Immediately Following a 10-Min Walk Predict Concurrent and Future Physical Activity?

Background

Affect may be important for understanding physical activity behavior.

Purpose

To examine whether affective valence (i.e., good/bad feelings) during and immediately following a brief walk predicts concurrent and future physical activity.

Methods

At months?6 and 12 of a 12-month physical activity promotion trial, healthy low-active adults (N?=?146) reported affective valence during and immediately following a 10-min treadmill walk. Dependent variables were self-reported minutes/week of lifestyle physical activity at months?6 and 12.

Results

Affect reported during the treadmill walk was cross-sectionally (month?6: ???=?28.6, p?=?0.008; month 12: ???=?26.6, p?=?0.021) and longitudinally (???=?14.8, p?=?0.030) associated with minutes/week of physical activity. Affect reported during a 2-min cool down was cross-sectionally (month 6: ???=?21.1, p?=?0.034; month 12: ???=?30.3, p?<?0.001), but not longitudinally associated with minutes/week of physical activity. Affect reported during a postcool-down seated rest was not associated with physical activity.

Conclusions

During-behavior affect is predictive of concurrent and future physical activity behavior.     

Patterns of treatment and associated short-term outcomes of unruptured intracranial aneurysms in children

Background

The rates and outcomes of treatments for intracranial aneurysms have not been exclusively determined within the pediatric population. We determined the rates of endovascular and microsurgical treatments for unruptured intracranial aneurysms (UIA) and associated rates of favorable outcome in patients aged <18 years.

Methods

We analyzed data obtained as part of the Kids’ Inpatient Database between 2003 and 2009 with primary diagnosis of UIA. Patients undergoing endovascular treatment were compared to those undergoing microsurgical treatment. We determined rates of intracerebral hemorrhage, subarachnoid hemorrhage, neurological complications, and favorable outcome.

Results

There were 818 cases of UIA during the study period. A total of 111 patients (mean age 14?±?6 years, 37.6 % female) underwent microsurgical treatment, and another 200 patients (mean age 13?±?7 years, 42.5 % female) underwent endovascular treatment. A high rate of favorable outcome was observed in patients who received either treatment (microsurgical treatment 87.7 % versus endovascular treatment 91.6 %, p?=?0.4). There was a trend towards a significantly shorter mean hospitalization stay among those who received endovascular treatment compared with microsurgical treatment (6?±?12 versus 9?±?11 days, p?=?0.06). There was a significant trend towards higher utilization of endovascular treatment as opposed to microsurgical treatment from 2003 to 2009 (p?=?0.02).

Conclusions

Although outcomes except for length of stay were comparable between endovascular treatment and microsurgical treatment patients, there was a trend towards higher utilization of endovascular treatment among children with UIAs from 2003 to 2009.     

Effect of delayed intermittent ventricular drainage on ventriculomegaly and neurological deficits in experimental neonatal hydrocephalus

Purpose

Evidence-based guidelines do not indicate when ventricular reservoirs should be placed in children with neonatal hydrocephalus, and delayed intervention is common. We hypothesize that delayed ventricular drainage has adverse effects on structural development and functional outcomes.

Methods

Using a well-established animal model of kaolin-induced obstructive hydrocephalus, we evaluated neurologic deficit after early (~1?week post-kaolin) or late (~2?weeks post-kaolin) placement of ventricular reservoirs which were tapped according to strict neurologic criteria.

Results

Progressive ventriculomegaly was similar in early- and late-reservoir implantation groups. The average neurologic deficit scores (NDSs) over the experimental period were 0 (n?=?6), 2.74 (n?=?5), and 2.01 (n?=?3) for the control, early-, and late-reservoir groups, respectively. At reservoir placement, early-group animals displayed enlarged ventricles without neurologic deficits (mean NDS?=?0.17), while the late group displayed ventriculomegaly with clinical signs of hydrocephalus (mean NDS?=?3.13). The correlation between ventriculomegaly severity and NDS in the early group was strongly positive in the acute (before surgery to 3?weeks post-reservoir placement) (R ²?=?0.65) and chronic (6 to 12?weeks post-reservoir placement) (R ²?=?0.65) phases, while the late group was less correlated (acute R ²?=?0.51; chronic R ²?=?0.19).

Conclusions

Current practice favors delaying reservoir implantation until signs of elevated intracranial pressure and neurologic deficit appear. Our results demonstrate that animals in early and late groups undergo the same course of ventriculomegaly. The findings also show that tapping reservoirs in these neonatal hydrocephalic animals based on neurologic deficit does not halt progressive ventricular enlargement and that neurologic deficit correlates strongly with ventricular enlargement.     

Self-Regulatory Fatigue,Quality of Life,Health Behaviors,and Coping in Patients with Hematologic Malignancies

Background

Self-regulatory fatigue may play an important role in a complex medical illness.

Purpose

Examine associations between self-regulatory fatigue, quality of life, and health behaviors in patients pre- (N?=?213) and 1-year post-hematopoietic stem cell transplantation (HSCT; N?=?140). Associations between self-regulatory fatigue and coping strategies pre-HSCT were also examined.

Method

Pre- and 1-year post-HSCT data collection. Hierarchical linear regression modeling.

Results

Higher self-regulatory fatigue pre-HSCT associated with lower overall, physical, social, emotional, and functional quality of life pre- (p’s?p’s?p?p?p?p’s?Conclusion This is the first study to show self-regulatory fatigue pre-HSCT relating to decreased quality of life and health behaviors, and predicting changes in these variables 1-year post-HSCT.     

Outcomes of Chiari I-associated scoliosis after intervention: a meta-analysis of the pediatric literature

Purpose

Various series have reported successful management of scoliosis after surgical treatment of the associated Chiari malformation, syrinx, or bracing. Multiple factors have been associated with curve progression, but interpretation of outcomes is confounded by the wide range of reported results and size of individual series. We attempted to evaluate the outcomes of Chiari I-associated scoliosis by performing a meta-analysis of currently published data.

Methods

We conducted a systematic review of published articles using Medline, PubMed (from 1950 to January 2010), and reference lists of identified articles for Chiari malformation and scoliosis.

Results

One hundred and twenty patients were identified in 12 studies, of them, 37?% were male. The mean age at the time of surgery was 9.7?±?4.1?years. The mean curve magnitude at presentation was 34.4?±?13.0° and progressed to a mean value of 38.9?±?20.2°, with an average follow-up of 48.3?±?48.2?months. After surgical intervention, curve magnitude improved in 37?% of patients (n?=?42); there was no change in 18?% (n?=?20), and curves progressed in 45?% (n?=?51). Age (p?=?0.0097) and presence of surgical intervention (foramen magnum decompression [p?=?0.0099] and syrinx shunting/drainage [p?=?0.0039]) were statistically associated with improvement of the scoliotic curve. Surgical decompression of the foramen magnum had the greatest impact on the scoliotic curves.

Conclusions

Data accrued from our analysis suggest that curve magnitude will improve after surgical treatment of the Chiari malformation in one third of patients, and curve progression will stabilize or improve in one half.