Minimally Invasive Endoscopic Surgery for Treatment of Spontaneous Intracerebral Hematomas: A Single-Center Analysis

Background

Endoscopic minimally invasive surgery to evacuate ICH has been reported to be more effective than conservative treatment or standard surgical craniotomy. However, most of these reports are based on Asian populations, while European reports do not exist. Here, we, therefore, report our experience from a European neurosurgical stroke center.

Methods

The variables assessed were patient characteristics, technical aspects of surgery, surgical complications, the outcomes grade of hematoma evacuation, 30-day mortality, and functional outcome (defined by modified Rankin Scale, mRS). The mRS was dichotomized into favorable (0–3) and unfavorable outcome (4–6). Mortality was compared to external evidence on conservatively and surgically treated patients by Poisson regression analysis with adjustment for ICH score.

Results

Thirty-four patients with ICH were analyzed. The mean age was 62 (standard deviation [SD] 12) years, mean hematoma volume (SD) was 84 (35) ml, and mean time from onset to surgery (SD) was 17 (10) h. Operative times did not exceed 1.5 h. A significant mean hematoma reduction (SD) from 84 (35) ml to 21 (30) ml (p < 0.0001) could be achieved, resulting in a median evacuation rate of 87 %. Early complications related to surgery did not occur. A favorable outcome was observed in 44 % of the patients. Overall, 30-day mortality was 18 %. The relative risk of mortality compared to conventional treatment from other studies was 32 % (95 % confidence interval 23–43 %, p = 0.02).

Conclusions

This European surgical stroke center series of an endoscopic operative technique demonstrates safety and efficacy with regard to reduction of hematoma size in patients with large and space-occupying spontaneous ICH. The study suggests that low mortality and acceptable outcomes may be achievable by minimally invasive hematoma surgery. Whether this technique reduces long-term morbidity compared to standard treatment needs to be further investigated in larger prospective randomized controlled trials.     

Subject-specific Patterns of Femur-labrum Contact are Complex and Vary in Asymptomatic Hips and Hips With Femoroacetabular Impingement

Background

Femoroacetabular impingement (FAI) may constrain hip articulation and cause chondrolabral damage, but to our knowledge, in vivo articulation and femur-labrum contact patterns have not been quantified.

Purpose

In this exploratory study, we describe the use of high-speed dual-fluoroscopy and model-based tracking to dynamically measure in vivo hip articulation and estimate the location of femur-labrum contact in six asymptomatic hips and three hips with FAI during the impingement examination. We asked: (1) Does femur-labrum contact occur at the terminal position of impingement? (2) Could range of motion (ROM) during the impingement examination appear decreased in hips with FAI? (3) Does the location of femur-labrum contact coincide with that of minimum bone-to-bone distance? (4) In the patients with FAI, does the location of femur-labrum contact qualitatively correspond to the location of damage observed intraoperatively?

Methods

High-speed dual-fluoroscopy images were acquired continuously as the impingement examination was performed. CT arthrogram images of all subjects were segmented to generate three-dimensional (3-D) surfaces for the pelvis, femur, and labrum. Model-based tracking of the fluoroscopy images enabled dynamic kinematic observation of the 3-D surfaces. At the terminal position of the examination, the region of minimal bone-to-bone distance was compared with the estimated location of femur-labrum contact. Each patient with FAI underwent hip arthroscopy; the location of femur-labrum contact was compared qualitatively with damage found during surgery. As an exploratory study, statistics were not performed.

Results

Femur-labrum contact was observed in both groups, but patterns of contact were subject-specific. At the terminal position of the impingement examination, internal rotation and adduction angles for each of the patients with FAI were less than the 95% confidence intervals (CIs) for the asymptomatic control subjects. The location of minimum bone-to-bone distance agreed with the region of femur-labrum contact in two of nine hips. The locations of chondrolabral damage identified during surgery qualitatively coincided with the region of femur-labrum contact.

Conclusions

Dual-fluoroscopy and model-based tracking provided the ability to assess hip kinematics in vivo during the entire impingement examination. The high variability in observed labrum-femur contact patterns at the terminal position of the examination provides evidence that subtle anatomic features could dictate underlying hip biomechanics. Although femur-labrum contact occurs in asymptomatic and symptomatic hips at the terminal position of the impingement examination, contact may occur at reduced adduction and internal rotation in patients with FAI. Use of minimum bone-to-bone distance may not appropriately identify the region of femur-labrum contact. Additional research, using a larger cohort and appropriate statistical tests, is required to confirm the findings of this exploratory study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-3919-9) contains supplementary material, which is available to authorized users.     

A case report of two male siblings with autism and duplication of Xq13–q21, a region including three genes predisposing for autism

Autism spectrum disorder, severe behaviour problems and duplication of the Xq12 to Xq13 region have recently been described in three male relatives. To describe the psychiatric comorbidity and dysmorphic features, including craniosynostosis, of two male siblings with autism and duplication of the Xq13 to Xq21 region, and attempt to narrow down the number of duplicated genes proposed to be leading to global developmental delay and autism. We performed DNA sequencing of certain exons of the TWIST1 gene, the FGFR2 gene and the FGFR3 gene. We also performed microarray analysis of the DNA. In addition to autism, the two male siblings exhibited severe learning disability, self-injurious behaviour, temper tantrums and hyperactivity, and had no communicative language. Chromosomal analyses were normal. Neither of the two siblings showed mutations of the sequenced exons known to produce craniosynostosis. The microarray analysis detected an extra copy of a region on the long arm of chromosome X, chromosome band Xq13.1–q21.1. Comparison of our two cases with previously described patients allowed us to identify three genes predisposing for autism in the duplicated chromosomal region. Sagittal craniosynostosis is also a new finding linked to the duplication.     

Vascular calcification is associated with impaired microcirculatory function in chronic haemodialysis patients

Although vascular calcification (VC) in dialysis patients is associated with increased cardiovascular events, the pathophysiology is still largely obscure. Microcirculatory dysfunction may contribute to demand myocardial ischaemia. We have studied cutaneous microcirculatory function in haemodialysis (HD) patients with and without large-vessel VC. 37 non-diabetic subjects (20 HD and 17 healthy controls) were studied. VC was assessed using CT scanning of a standardised segment of superficial femoral artery (11 VC+, 9 VC-). Laser Doppler imaging was undertaken using a Periscan PIM II(R) at rest and under vasodilator challenge. Baseline perfusion was not statistically different in VC+ patients than VC- patients or controls (1.03 +/- 0.2, 1.08 +/- 0.2, 0.93 +/- 0.3 PU respectively). Overall, the maximum vasodilatory response to both ACh (p < 0.001) and SNP (p = 0.004) was lower in the HD than the control group. In addition, the HD patients took longer to reach a maximum vasodilatation than the controls (p = 0.008 for ACh, n.s. for SNP). Further, the maximum vasodilatory response in the VC+ patients was lower and patients took longer to reach maximum vasodilatation than the VC- group. We have demonstrated, for the first time, impaired and dysregulated microcirculatory function in patients with VC. This may be important in understanding the pathophysiology of the complications and cardiovascular consequences of VC.     

Informed Consent for Medical Research: Common Discrepancies and Readability

Objective: To identify common discrepancies and average reading grade levels for informed consent forms (ICFs) us submitted to institutional review boards (IRBs) by medical researchers.
Methods: A retrospective evaluation of ICFs as submitted to IRBs of 3 university-affiliated hospitals during a I-year period. ICF content was evaluated using a checklist of 23 requirements specified in the federal regulations governing human research. Documents then were computer-analyzed to determine the readability scores using 2 common indexes of comprehension. A discrepancy was defined as any instance in which an ICF did not address an applicable requirement in the Code of Federal Regulations.
Results: Eighty-two ICFs representing 16 medical specialties were evaluated; 8 (10%) were from emergency medicine. Eighteen ICFs (22%) were conspicuously incomplete, lacking 29 federal requirements. The mean number of discrepancies was 4.7 (95% CI, 3.9–5.5) Common omissions included: a statement about who is doing the research, number of subjects in the study, circumstances when a subject's participation may be terminated, disclosure of alternative procedures, and notice to subjects regarding new findings. The mean Flesch grade level required to read all ICFs was 13.8 (95% CI, 13.5–14.2), implying that the majority of the U.S. adult population would be unable to comprehend these forms.
Conclusion: Designing a consent form to meet all of the federal requirements while maintaining a level of reading comprehension suitable for the general population is a difficult task for investigators.     

Home Telehealth Uptake and Continued Use Among Heart Failure and Chronic Obstructive Pulmonary Disease Patients: a Systematic Review

Background

Home telehealth has the potential to benefit heart failure (HF) and chronic obstructive pulmonary disease (COPD) patients, however large-scale deployment is yet to be achieved.

Purpose

The aim of this review was to assess levels of uptake of home telehealth by patients with HF and COPD and the factors that determine whether patients do or do not accept and continue to use telehealth.

Methods

This research performs a narrative synthesis of the results from included studies.

Results

Thirty-seven studies met the inclusion criteria. Studies that reported rates of refusal and/or withdrawal found that almost one third of patients who were offered telehealth refused and one fifth of participants who did accept later abandoned telehealth. Seven barriers to, and nine facilitators of, home telehealth use were identified.

Conclusions

Research reports need to provide more details regarding telehealth refusal and abandonment, in order to understand the reasons why patients decide not to use telehealth.