Third ventriculostomy for internal hydrocephalus complicated by unrecognized subdural hygroma and hematoma: a case report of a patient treated by Dr. Walter Dandy

The authors review the case of a patient treated by Dr. Walter Dandy. When the patient was a young child he underwent two right transtemporal third ventriculostomies during which he sustained an unrecognized contralateral subdural hygroma and a chronic subdural hematoma with a mild infantile hemiparesis. He was able to complete high school, albeit at a slower pace than usual. As an adult he held several limited employment positions, lived at home for several decades, and was later cared for at a nursing home for a short time. The patient died when he was 66 years of age.     

Risperidone treatment of motor restlessness following anoxic brain injury

Primary objective: This paper examined the use of an atypical neuroleptic medication, risperidone, in reducing the excessive motor activity of an adolescent with an anoxic brain injury following cardiac arrest from a lightning strike. Lower extremity restlessness caused the patient to develop skin breakdown and interfered with healing of existing burns.

Research design: Single-blind, placebo-controlled single-subject experimental design.

Experimental intervention: Escalating doses of risperidone up to 1 mg and in combination with methylphenidate (10 mg) and amantidine (100 mg).

Main outcomes and results: The patient demonstrated a reduction in restlessness in response to the use of risperidone, which permitted wound healing. The addition of methlphenidate to risperidone led to a slight increase in attention to task.

Conclusions: The use of the atypical neuroleptic medication, risperidone, may be considered as part of the armamentarium available to physicians treating restlessness in severe brain injuries.     

Safety of gadolinium contrast angiography in patients with chronic renal insufficiency

OBJECTIVE: To prevent iodinated contrast medium-induced nephrotoxicity, gadolinium has been used increasingly for magnetic resonance angiography (MRA) or conventional digital subtraction angiography (DSA) to visualize arterial anatomy in patients undergoing vascular surgery who are considered at high risk because of chronic renal insufficiency. We assessed the safety of gadolinium-based contrast medium as a substitute for iodinated contrast medium-enhanced examinations. We determined the incidence of gadolinium-induced nephrotoxicity in a clinical setting and searched for contributing risk factors.Patients and methods In a single-center retrospective study from December 1999 to January 2001, 218 inpatients underwent MRA and 42 inpatients underwent DSA, with gadolinium as the sole contrast agent. Patient comorbid conditions, indications for vascular imaging, contrast dose, urine output, baseline and post-procedure serum creatinine concentration (SCr), and outcome were recorded for all patients in whom gadolinium-induced renal failure developed. RESULTS: Of 260 patients who received gadolinium-based contrast agents, at a dose of 0.25 mmol/kg or more, 195 patients (75%) had pre-test baseline chronic renal insufficiency. In 7 of 195 patients (3.5%) acute renal failure developed after gadolinium-based contrast medium administration, for MRA (n = 153) in 3 patients (1.9%) and DSA (n = 42) in 4 patients (9.5%). Average baseline SCr in the 195 patients with chronic renal insufficiency was 38.2 +/- 1.6 mL/min/1.73 m(2), and in the 7 patients in whom acute renal failure developed, baseline SCr was 32.5 +/- 7.8 mL/min/1.73 m(2) (P =.33). Respective intravenous and intra-arterial gadolinium doses in these 7 patients ranged from 0.31 to 0.41 mmol/kg for MRA and 0.27 to 0.42 mmol/kg for DSA. Acute renal failure did not develop in any of 65 patients with normal baseline SCr. CONCLUSION: Despite reports of negligible nephrotoxicity, rarely gadolinium-based contrast agents can cause acute renal failure in patients with underlying chronic renal insufficiency. Estimation of creatinine clearance alone does not enable prediction of which patients are likely to have acute renal failure. Patients at high-risk should be identified, and prophylactic measures should be taken to reduce the risk for nephrotoxicity.     

Hypersensitive knockin mouse strains identify receptors and pathways for nicotine action

Two series of knockin mouse strains have been constructed with point mutations that result in hypersensitive neuronal nicotinic acetylcholine receptors containing alpha 4- or alpha 7-subunits. The full expression of the stronger alleles produces neonatal excitotoxic lethality; however, mice with attenuated expression or milder alleles are viable, and display a range of hypersensitive responses to nicotine. To date, measurements have been made on nicotine-induced seizures, Straub tail, hypothermia, antinociception, electroencephalograms and cellular electrophysiological responses. These strains are helping to define the occurrence of these important receptor subtypes, and their role in the acute and chronic actions of nicotine. The hypersensitive strains may be useful for the development of nicotinic drug therapy.     

Protein-energy malnutrition and involuntary weight loss: nutritional and pharmacological strategies to enhance wound healing

Clinically significant involuntary weight loss (IWL) is defined as a loss of 4.5 kg or > 5% of the usual body weight over a period of 6 - 12 months, especially when progressive. Weight loss of > 10% of normal body weight is considered to represent protein-energy malnutrition (PEM). Despite progress in our understanding of the aetiology and pathophysiology of IWL and PEM, these conditions remain frequent and serious problems in several high-risk populations in both acute and long-term care facilities. In patients with IWL and PEM, nonhealing wounds signal a catabolic process that requires prompt nutritional intervention. Aggressive nutritional therapy that provides adequate protein, calories and micronutrients, combined with an anabolic agent such as oxandrolone, may provide the most optimal environment for restoration of lean body mass and body weight and in turn, promote wound healing. More research, however, is needed to define optimal nutritional and anabolic therapies for these patients given the associated high morbidity and cost of care.     

Does deliberation make a difference? Results from a citizens panel study of health goals priority setting

How to involve the public in setting health and health care priorities is a constant challenge for health system decisions. Policy maker interest in involving the public in increasingly complex and value-laden priority setting processes has led to the use of deliberative public involvement methods designed to promote discussion and debate among participants with the objective of obtaining more informed and consensual views. These methods have not been evaluated rigorously using controlled designs with pre- and post-test measurements. We examined, using a controlled design, the effects of introducing different opportunities for deliberation into a process for obtaining public input into a community health goals priority setting process. Our findings indicate that deliberation does make a difference to participant views. As more deliberation is introduced, participant views may be more amenable to change. Deliberation also offers the potential for views to become more rather than less entrenched. While we are beginning to understand the difference deliberation makes to participant views, we are still at an early stage in understanding the process through which these differences come about and what difference deliberation makes to broader outcomes such as civic competence, civic engagement and health policy decisions.     

Evaluation of factors determining the precision of body composition measurements by air displacement plethysmography

OBJECTIVES: To investigate methodological precision of air displacement plethysmography for assessment of body composition in a heterogenous sample of adults. DESIGN: Accuracy of volume measurements by air displacement plethysmography (ADP) for a range of known volumes was ascertained. Repeated measurements of body volume, lung volume, and derived body composition using the BODPOD measurement system were performed. Influence of surface area estimation on ADP measurement was investigated as a possible source of variation. SETTING: Clinical Nutrition Laboratory, School of Health & Sports Science, University of North London, London, UK. SUBJECTS: One hundred and two healthy subjects (57 women, 45 men) who ranged in age between 16 and 55 y and in BMI (kg/m(2)) between 17.8 and 41.9. STUDY DESIGN: Cross-sectional study of healthy adults for comparison with previous studies. Repeat measurements of raw body volume, lung volume and % body fat (BF) by ADP were all performed on the same day. RESULTS: From the range of known volumes a marked increase in the CV and a significantly greater measurement error were found at volumes below 40 l (P=0.04). Repeat measurements of raw body volume in human subjects resulted in a technical error equivalent to 0.8% BF. There was no significant difference found between measured and predicted lung volume and the 95% confidence interval for difference was only 0.3% BF. Repeat measurements of lung volume in our subset resulted in a technical error equivalent to 0.5% BF. Although body surface area estimation only accounted for variation in % BF of 0.1%, the extent of variation appeared to be governed by leanness (P<0.001). CONCLUSIONS: Although ADP retains excellent precision, in practice, repeat measurements of ADP should be performed whenever possible to allow for erroneous volume measurement within one procedure. Protocols for ADP measurement should be created with an awareness of those factors, which may affect measurements. SPONSORSHIPS: This study was supported by the University of North London Diversity & Development Fund.     

Pretesting survey instruments: An overview of cognitive methods

This article puts forward the case that survey questionnaires, which are a type of measuring instrument, can and should be tested to ensure they meet their purpose. Traditionally survey researchers have been pre-occupied with standardising data collection instruments and procedures such as question wording and have assumed that experience in questionnaire design, coupled with pilot testing of questionnaires, will then ensure valid and reliable results. However, implicit in the notion of standardisation are the assumptions that respondents are able to understand the questions being asked, that questions are understood in the same way by all respondents, and that respondents are willing and able to answer such questions. The development of cognitive question testing methods has provided social researchers with a number of theories and tools to test these assumptions, and to develop better survey instruments and questionnaires. This paper describes some of these theories and tools, and argues that cognitive testing should be a standard part of the development process of any survey instrument.     

Combined video-assisted thoracoscopic lung volume reduction surgery and lobectomy in a high-risk patient

Nonsmall cell lung cancer often occurs in patients with severe emphysema. Lobectomy in these patients is often contraindicated due to extensive parenchymal destruction and subsequent pulmonary insufficiency. Video-assisted thoracoscopic lobectomy has been described as a less morbid procedure in high-risk patients. Lung volume reduction surgery has been shown to improve pulmonary function in selected patients with emphysema. We describe the successful combination of lobectomy and lung volume reduction surgery (LVRS) with a video-assisted thoracoscopic (VATS) approach in a high-risk patient with Stage I nonsmall cell lung cancer.     

PoleStriding exercise and vitamin E for management of peripheral vascular disease

PURPOSE: The purpose of this investigation was to evaluate the efficacy of PoleStriding exercise (a form of walking that uses muscles of the upper and lower body in a continuous movement similar to cross-country skiing) and vitamin E (alpha-tocopherol) to improve walking ability and perceived quality of life (QOL) of patients with claudication pain secondary to peripheral arterial disease (PAD). METHODS: Fifty-two subjects were randomized into four groups: PoleStriding with vitamin E (N = 13), PoleStriding with placebo (N= 14), vitamin E without exercise (N= 13), and placebo without exercise (N = 12). The dose of vitamin E was 400 IU daily. Only the PoleStriding with vitamin E and PoleStriding with placebo groups received PoleStriding instruction and training. Assignment to vitamin E or placebo was double blind. Subjects trained three times weekly for 30-45 min (rest time excluded). Individuals in vitamin E and placebo groups came to the laboratory biweekly for ankle blood-pressure measurements. RESULTS: Results of this randomized clinical trial provide strong evidence that PoleStriding significantly (P< 0.001) improved exercise tolerance on the constant work-rate and incremental treadmill tests. Ratings of perceived claudication pain were significantly less after the PoleStriding training program (P= 0.02). In contrast, vitamin E did not have a statistically significant effect on the subjects' ratings of perceived leg pain (P= 0.35) or treadmill walking duration ( P= 0.36). Perceived distance and walking speed (Walking Impairment Questionnaire) and perceived physical function (Rand Short Form-36) improved in the PoleStriding trained group only (P< 0.001, 0.022 and 0.003, respectively). CONCLUSION: PoleStriding effectively improved the exercise tolerance and perceived QOL of patients with PAD. Little additional benefit to exercise capacity was realized from vitamin E supplementation.