Craniotomy for meningioma in the United States between 1988 and 2000: decreasing rate of mortality and the effect of provider caseload

OBJECT: The goal of this study was to determine the risk of adverse outcomes after contemporary surgical treatment of meningiomas in the US and trends in patient outcomes and patterns of care. METHODS: The authors performed a retrospective cohort study by using the Nationwide Inpatient Sample covering the period of 1988 to 2000. Multivariate regression models with disposition end points of death and hospital discharge were used to test patient, surgeon, and hospital characteristics, including volume of care, as outcome predictors. Multivariate analyses revealed that larger-volume centers had lower mortality rates for patients who underwent craniotomy for meningioma (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.59-0.93, p = 0.01). Adverse discharge disposition was also less likely at high-volume hospitals (OR 0.71, 95% CI 0.62-0.80, p < 0.001). With respect to the surgeon caseload, there was a trend toward a lower rate of mortality after surgery when higher-caseload providers were involved, and a significantly less frequent adverse discharge disposition (OR 0.71, 95% CI 0.62-0.80, p < 0.001). The annual meningioma caseload in the US increased 83% between 1988 and 2000, from 3900 patients/year to 7200 patients/year. In-hospital mortality rates decreased 61%, from 4.5% in 1988 to 1.8% in 2000. Reductions in the mortality rates were largest at high-volume centers (a 72% reduction in the relative mortality rate at largest-volume-quintile centers, compared with a 6% increase in the relative mortality rate at lowest-volume-quintile centers). The number of US hospitals where craniotomies were performed for meningiomas increased slightly. Fewer centers hosted one meningioma resection annually, whereas the largest centers had disproportionate increases in their caseloads, indicating a modest centralization of meningioma surgery in the US during this interval. CONCLUSIONS: The mortality and adverse hospital discharge disposition rates were lower when meningioma surgery was performed by high-volume providers. The annual US caseload increased, whereas the mortality rates decreased, especially at high-volume centers.     

Reduction in Fracture Rate and Back Pain and Increased Quality of Life in Postmenopausal Women Treated with Teriparatide: 18-Month Data from the European Forsteo Observational Study (EFOS)

The European Forsteo Observational Study was designed to examine the effectiveness of teriparatide in postmenopausal women with osteoporosis treated for up to 18 months in normal clinical practice in eight European countries. The incidence of clinical vertebral and nonvertebral fragility fractures, back pain, and health-related quality of life (HRQoL, EQ-5D) were assessed. Spontaneous reports of adverse events were collected. All 1,648 enrolled women were teriparatide treatment-naive, 91.0% of them had previously received other anti-osteoporosis drugs, and 72.8% completed the 18-month study. A total of 168 incident clinical fractures were sustained by 138 (8.8%) women (821 fractures/10,000 patient-years). A 47% decrease in the odds of fracture in the last 6-month period compared to the first 6-month period was observed (P < 0.005). Mean back pain VAS was reduced by 25.8 mm at end point (P < 0.001). Mean change from baseline in EQ-VAS was 13 mm by 18 months. The largest improvements were reported in the EQ-5D subdomains of usual activities and pain/discomfort. There were 365 adverse events spontaneously reported, of which 48.0% were considered related to teriparatide; adverse events were the reason for discontinuation for 79 (5.8%) patients. In conclusion, postmenopausal women with severe osteoporosis who were prescribed teriparatide in standard clinical practice had a significant reduction in the incidence of fragility fractures and a reduction in back pain over an 18-month treatment period. This was associated with a clinically significant improvement in HRQoL. Safety was consistent with current prescribing information. These results should be interpreted in the context of the open-label, noncontrolled design of the study.     

J‐difference editing of gamma‐aminobutyric acid (GABA): Simulated and experimental multiplet patterns

Purpose : To investigate factors that influence the multiplet pattern observed in J‐difference editing of gamma‐aminobutyric acid (GABA). Methods : Density matrix simulations were applied to investigate the shape of the 3 ppm GABA multiplet as a function of the editing sequence's slice‐selective refocusing pulse properties, in particular bandwidth, transition width, and flip angle. For comparison to the calculations, experimental measurements were also made at 3 T on a 10 mM GABA solution using the MEGA‐PRESS sequence at various refocusing pulse flip angles. Results : Good agreement was found between experiments and simulations. The edited multiplet consists of two outer lines of slightly unequal intensity due to strong coupling, and a smaller central line, the result of the unequal J‐couplings between the C4 and C3 protons. The size of the center peak increases with increasing slice‐selective refocusing pulse transition width, and deviation of the flip angle from 180°. Conclusion : The 3 ppm GABA multiplet pattern observed in the MEGA‐PRESS experiment depends quite strongly on the properties of the slice‐selective refocusing pulses used. Under some circumstance, the central peak can be quite large; this does not necessarily indicate inefficient editing, or a subtraction artifact, but should be recognized as a property of the pulse sequence itself. Magn Reson Med 70:1183–1191, 2013. © 2012 Wiley Periodicals, Inc.     

Proton MR spectroscopy in acute middle cerebral artery stroke.

PURPOSETo investigate the feasibility of performing multisection proton MR spectroscopy in patients with acute stroke, and to determine whether this imaging technique can depict ischemic or infarcted brain regions.METHODSMultisection proton MR spectroscopy, MR imaging, and MR angiography were performed within 24 hours of stroke onset (mean, 12 hours) in 12 patients who had had a stroke of the middle cerebral artery. Spectra were analyzed from brain regions containing T2 hyperintensity abnormalities on MR images, from regions immediately adjacent to these abnormalities, and from anatomically similar contralateral regions. Areas of brain containing lactate were compared with areas of T2 hyperintensities on MR images.RESULTSOne data set was discarded because of excessive artifacts from patient motion. Regions of T2 hyperintensities on MR images were found to contain elevated lactate (all 11 cases) and reduced N-acetyl-aspartate (10 of 11 cases) relative to contralateral measurements. Lactate levels in regions adjacent to T2 hyperintensities were not significantly different from those of infarcted brain. On the other hand, N-acetyl-aspartate was significantly lower in regions of infarction compared with periinfarct tissue. Areas of brain containing elevated lactate significantly exceeded those of T2 abnormality.CONCLUSIONSProton MR spectroscopy is feasible for imaging patients with acute stroke. In the early stages of stroke, tissue containing elevated lactate but no other spectroscopic or MR imaging abnormality can be identified. Such regions may represent an ischemic zone at risk of infarction.     

Development of a therapeutic adenoviral vector for cholangiocarcinoma combining tumor-restricted gene expression and infectivity enhancement

Cholangiocarcinoma is an invasive malignancy that is most often unresectable upon diagnosis and unresponsive to chemotherapy and radiation. While adenoviral gene therapy has shown promise in treating many tumors, systemic toxicity and low tumor transduction efficiency have hampered its application in many gastrointestinal cancers. To overcome these difficulties, we have constructed an adenoviral vector utilizing a tumor-specific promoter (TSP) for selective transgene expression and a vector with an RGD-motif in the fiber-knob region for infectivity enhancement. In seeking a TSP for cholangiocarcinoma, Secretory Leukoprotease Inhibitor, Midkine, Gastrin Releasing Peptide, VEGF, Cox-2M, and Cox-2L promoters were configures in adenoviral vectors, and evaluated in cholangiocarcinoma cells lines (Oz and SkChA-1). Luciferase assays demonstrated that Cox-2 promoters (M and L) showed the highest promoter activity, with Cox-2M appearing slightly stronger than Cox-2L. Infectivity enhanced vectors with RGD-motif in the fiber-knob region were also constructed with the luciferase transgene driven by a CMV control and the Cox-2M and Cox-2L promoters. Subsequent luciferase assays comparing the unmodified vectors to the RGD-modified versions demonstrated higher levels of luciferase activity than the RGD-infected cells. This paradigm was then applied to a therapeutic HSV-TK/GCV model by constructing RGD-enhanced HSV-TK vectors driven by Cox-2M and Cox-2L promoters. In vitro cytocidal effect analysis confirmed that the RGD-modified, cox-2 (M and L) driven vectors showed a stronger cytocidal effect upon gancyclovir administration than the vectors with wild-type fiber. The Cox-2 promoter demonstrates a favorable selectivity profile for cholangiocarcinoma, and RGD-modification further enhances transduction efficiency. This combination has potential to overcome the obstacles to clinical application of adenoviral gene therapy in cholangiocarcinoma. Presented at the Forty-Third Annual Meeting of The Society for Surgery of The Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

The acute effect of magnetic stimulation of the pelvic floor on involuntary detrusor activity during natural filling and overactive bladder symptoms

OBJECTIVE: To evaluate the effect of magnetic stimulation of the pelvic floor (MSPF) on involuntary detrusor activity observed during natural filling, and on the overactive bladder symptom complex. PATIENTS AND METHODS: Eighteen women with detrusor overactivity on conventional cystometry underwent ambulatory urodynamic monitoring over two filling cycles. Fluid intake was standardized, provocative manoeuvres applied at regular intervals and symptoms documented contemporaneously. During the second filling cycle MSPF was delivered whenever the detrusor pressure increased by > 5 cmH2O. The women were subsequently treated with MSPF for 6 weeks; their lower urinary tract symptoms were assessed before and after treatment. RESULTS: Comparing the second (stimulated) cycle with the first (unstimulated) cycle, cystometric capacity was higher (373 vs 224 mL, P < 0.03). and involuntary detrusor activity of shorter duration (370 vs 427 s, P < 0.82) and lower amplitude (53 vs 63 cmH2O, P < or = 0.05). All women tolerated the procedure comfortably, but nine found it too time-consuming and withdrew. In the nine women who completed treatment there was no consistent change in overactive bladder symptoms. CONCLUSIONS: In this pilot study, MSPF during natural filling was associated with a decrease in the amplitude of involuntary detrusor contractions and a significant increase in cystometric capacity. However, MSPF had a variable effect on sensations of urgency, both acutely and after treatment, and currently there is no evidence to suggest that MSPF has an enduring effect on symptoms of the overactive bladder.