"Curtain-fall" technique for cerebrospinal fluid leak prevention after removal of intradural drainage. Technical note: application in chronic subdural hematoma surgery.

OBJECTIVE: Chronic subdural hematoma (CSDH) is frequently met in neurosurgical practice and often need urgent surgical treatment in case of neurological deterioration. Different surgical approaches to evacuate CSDH are described in the literature. In our experience, an external drainage system is crucial in order to avoid recurrences. We recently encountered a case of subcutaneous CSF collection after drainage removal. Thus, we developed a simple surgical technique to prevent postoperative CSF leak after subdural drainage system removal. METHOD: We have developed a technique in which the periosteum is harvested during the surgery prior to the evacuation of the hemorrhage and fixed with sutures on the uncut dura mater opposite and laterally to the exit of the catheter exiting the dural hole caused by the passage of the Jackson-Pratt subdural drainage system. When the drainage catheter is removed, the flap, partially held by the sutures, falls over the hole avoiding CSF leakage. By using this technique, the small dural hole will be covered with the periosteum allowing for natural closure and wound healing hence preventing CSF leakage. RESULTS: This technique was successfully employed in 21 patients who didn't develop postoperative CSF leakage following CSDH evacuation and removal of subdural drainage system. CONCLUSION: In this technical note, we describe a safe dura closure technique that we developed to help reduce the risk of postoperative CSF leakage following subdural drainage removal, which can, however, also be applied in all surgeries in which a catheter is placed in the subdural space.

Novel echocardiographic score to predict duct-dependency after percutaneous relief of critical pulmonary valve stenosis/atresia.

OBJECTIVES: This study aimed to identify clinical, hemodynamic, or echocardiographic predictive features of persistent duct-dependency of pulmonary circulation (PDDPC) after effective percutaneous relief of pulmonary atresia with the intact ventricular septum (PA-IVS) or critical pulmonary stenosis (CPS). METHODS: From 2010 to 2021, 55 neonates with PA-IVS or CPS underwent percutaneous right ventricle (RV) decompression at our Institution. After successfully relief of critical obstruction, 27 patients (group I) showed PDDPC, whereas RV was able to support the pulmonary circulation in the remaining 28 patients (group II). Clinical, hemodynamic, and echocardiographic features of these two groups were compared. RESULTS: No significant difference in clinical and hemodynamic data was found between the groups, although the group I had a lower oxygen saturation at hospital admission. However, tricuspid valve (TV) diameter <8.8 mm, TV z-score ←2.12, tricuspid/mitral valve annular ratio <.78, pulmonary valve diameter <6.7 mm, pulmonary valve z-score ←1.17, end-diastolic RV area <1.35 cm2 , end-systolic right atrium area >2.45 cm2 , percentage amount of interatrial right-to-left shunt >69.5%, moderate/severe tricuspid regurgitation, RV systolic pressure >42.5 mmHg, tricuspid E/E' ratio >6.6 showed each significant predictive value of PDDPC. These parameters were used to build a composite echocardiographic score (PDDPC-score), assigning one point each above the respective cut-off value. A score ≥4.00 showed high sensitivity (100%) and specificity (86%) in predicting PDDPC. CONCLUSION: Clinical and hemodynamic features fail to predict the short-term fate of the pulmonary circulation after successful treatment of PA-IVS/CPS. However, a simple, composite echocardiographic score is useful to predict PDDPC and could be crucial in the management of this frail subset of patients.

Simulation training program for vacuum application to improve technical skills in vacuum-assisted vaginal delivery.

OBJECTIVE: evaluation of technical skills of the operators during the obstetrical device application for operative vaginal delivery, named kiwi-cup in a simulation training program. METHODS: Thirty-five residents in obstetrics and gynecology of the University of Pisa, Italy were recruited and evaluated with an assessment scale on technical skills from 0 to 55 points. They performed various operative vaginal delivery simulations with kiwi-cup and were evaluated at time 0 by a tutor. After 8 weeks, simulation training was repeated and trainees were re-evaluated by the same tutor. RESULTS: after 8 weeks from the first simulation session, trainees have been shown to increase technical skills (46.27 ± 4.6 with p-value < 0.0001), the successful application rate (85.71% with p-value 0.0161).) and to reduce the time to complete the procedure (86.2 ± 29.9 s with p-value < 0.0001). CONCLUSION: simulation training on operational vaginal delivery significantly increases technical skills, improves successful rate, and reduces the time taken to complete the procedure. CLINICAL TRIAL REGISTRATION: Not applicable.

Emotional Distress, Self-Management Skills, and Expectations Among Adolescents and Young Adult Childhood Cancer Survivors in Transition from Pediatric to Adult Care: A Brief Report.

The transition from pediatric to adult care poses several emotional and personal challenges to adolescents and young adult (AYA) childhood cancer survivors (CCSs), which need attention to avoid the risk of nonadherence and medical dropout. This brief report describes the condition of AYA-CCSs at the moment of transition in terms of emotional state, personal autonomy, and expectations regarding future care. The results provide insights for clinicians dealing with survivorship care, to enhance AYA-CCSs emotional resilience and to support them in being in charge of their health, thus facilitating their transition to adulthood.

Elderly Patients with Frontobasal and Suprasellar Meningiomas: Safety and Efficacy of Tumor Removal via Frontolateral Approach.

OBJECTIVE: Many neurosurgeons prefer conservative treatments in the elderly because of higher rates of mortality and morbidity after surgery. We aim to evaluate safety and efficacy of surgery in elderly patients with frontobasal and suprasellar meningiomas with a simple operative procedure, the frontolateral approach. METHODS: Retrospective analysis was made in consecutive patients with meningiomas operated via frontolateral approach. They were divided into 2 groups: elderly group (age ≥ 65 years) and young group (age < 65 years). Multivariate logistic regression analysis was performed for postoperative complications and Karnofsky Performance Scale score (KPS). RESULTS: The study comprises 128 patients operated over a 19-year period, of which 35 patients were in the elderly group and 93 patients were in the young group. More elderly patients presented with American Society of Anesthesiology (ASA) class II and III (57.1% vs. 43%). Gross resection was achieved in 31 cases in the elderly and 85 cases in young group (88.6% vs. 90.3%, P = 0.17). Postoperative KPS in both groups was improved (85.7% vs. 91.4%, P = 0.18). One death occurred in elderly group (2.9%, P = 0.27). Approach-related and medical morbidity in the elderly group was slightly higher than in the young group without significant difference (respectively, 11.4% and 14.3% vs. 9.7% and 8.6%, P = 0.18). Multivariate logistic regression showed increasing age was not associated with approach-related morbidity (odds ratio [OR]: 1.39, P = 0.53), medical morbidity (OR: 1.94, P = 0.88), and improvement of KPS (OR: 0.32, P = 0.25). CONCLUSIONS: Frontobasal and suprasellar meningiomas in elderly patients can be treated surgically with acceptably low morbidity and mortality rates via the frontolateral approach. Preoperative KPS score ≤60 and ASA classification ≥III predict an unfavorable postoperative outcome.

Surgical management of cerebellopontine angle arachnoid cysts associated with hearing deficit in pediatric patients.

OBJECTIVE Few cases of cerebellopontine angle (CPA) arachnoid cysts in pediatric patients have been described in the literature, and in only 2 of these cases were the patients described as suffering from hearing deficit. In this article, the authors report on 3 pediatric patients with CPA arachnoid cysts (2 with hearing loss and 1 with recurrent headaches) who underwent neurosurgical treatment at the authors' institution. METHODS Four pediatric patients were diagnosed with CPA arachnoid cysts at the International Neuroscience Institute during the period from October 2004 through August 2012, and 3 of these patients underwent surgical treatment. The authors describe the patients' clinical symptoms, the surgical approach, and the results on long-term follow-up. RESULTS One patient (age 14 years) who presented with headache (without hearing deficit) became asymptomatic after surgical treatment. The other 2 patients who underwent surgical treatment both had hearing loss. One of these children (age 9 years) had recent-onset hypacusia and experienced complete recovery immediately after the surgery. The other (age 6 years) had a longer history (2 years) of progressive hearing loss and showed an interruption of the deficit progression and only mild improvement at the follow-up visit. CONCLUSIONS CPA arachnoid cysts are uncommon in pediatric patients. The indication and timing of the surgical treatment are fundamental, especially when a hearing deficit is present.

Redo third ventriculostomy.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is the treatment of choice for obstructive hydrocephalus. In some cases a reclosure of the ventriculostoma occurs. This could be caused by different reasons, such as operative technique, size of the stoma, scarring, or a persisting Liliequist membrane. METHODS: The databases of the Neurosurgical Department of the Philipps University Marburg and the International Neuroscience Institute Hannover have been explored. The medical reports of patients who suffered from hydrocephalus and were treated with ETV between 1990 and 2010 were reviewed, with special consideration of a nonpatent ventriculostoma and a repeated ETV. RESULTS: Of 148 patients with ETV, we had 14 patients in whom the stoma was not patent. In 8 of those, we performed a successful second ventriculostomy. Five patients were treated with application of a ventriculoperitoneal shunt. One patient died of an acute obstructive hydrocephalus due to the closure of the ventriculostoma. The success rate of repeat ETV has been 87.5%. CONCLUSIONS: In cases of secondary closure of the stoma after ETV, an endoscopic reventriculostomy is recommended using the same operative approach and should be taken into consideration before the application of a cerebrospinal fluid diversion system.

Conduta na dor e prurido vulvar / Pain and pruritus vulvae management

Prurido e dor são as principais manifestações clínicas das doenças vulvares. Estes sintomas podem estar associados a processos inflamatórios, imunológicos, distúrbios metabólicos e neoplasias. Na dúvida, é sempre recomendável o estudo histopatológico. Quando não há definição etiológica, várias opções terapêuticas estão disponíveis: cremes tópicos, fármacos sistêmicos, operações de dessensibilização nervosa da vulva. A conduta terapêutica deve ser individualizada quando não há etiologia definida. São escassos os trabalhos científicos, com metodologia adequada, que abordam o tema. Portanto, anamnese e exame físico cuidadosos irão definir a melhor abordagem terapêutica

Pruritus and pain are common manifestations of vulvae diseases. The symptoms can be associated with inflammatory, immunologic, metabolic or neoplastic diseases. Undoubtedly, the histopathological exam is always recommended. When there is no etiologic definition, many therapeutic options are available: creams, systemic drugs, and surgical neural desensitization of the vulvae. When there is no precise etiology, therapeutical approach must be individualized. Scientific studies, with good methodology, are rare. Therefore, careful anamnesis and physical exam will point to the best therapeutical approach

Eficácia, tolerabilidade, controle de ciclo e bem-estar em mulheres acima de 35 anos utilizando um contraceptivo de baixa dose contendo gestodeno e etinilestradiol (Harmonet) / Efficacy, tolerability, cycle control and welfare in woman above 35 years using a low dose contraceptive containing gestodene and ethynilestradiol (Harmonet)

Um estudo multicêntrico foi conduzido em 14 centros brasileiros para avaliar a eficácia, tolerabilidade, controle de ciclo e bem-estar em mulheres, não fumantes, acima de 35 anos utilizando um contraceptivo de baixa dose contendo gestodeno e etinilestradiol, durante seis ciclos de tratamento. Participaram do estudo 180 mulheres na faixa etária de 35 a 47 anos, das quais 158 (87,8 por cento) completaram os seis ciclos de tratamento. Nenhuma gravidez ocorreu entre as usuárias do contraceptivo em estudo. Um total de 950 ciclos foi avaliado. Em 92,5 por cento dos ciclos não houve spotting nem sangramento de escape. Ocorreu spotting em 7,2 por cento dos ciclos e sangramento de escape em 0,3 por cento dos ciclos. Com relação ao número de mulheres, 82,2 por cento não apresentaram spotting nem sangramento de escape em nenhum momento do ciclo. Observou-se uma diminuição significativa, indicativa de melhora, com relação ao pré-tratamento, nos escores do questionário de Moos de desconforto menstrual relativos a dor, concentração, mudanças comportamentais, afeto negativo, reações autonômicas, retenção hídrica e controle. Não houve alterações clinicamente significativas de peso, pressão arterial nem resultados laboratoriais. A adesão ao tratamento foi boa, tendo havido esquecimento de tomada de uma ou mais pílulas em apenas 3 por cento do total de ciclos; 12,2 por cento das mulheres não completaram o período de seis ciclos de tratamento, sendo que em 1,1 por cento dos casos a razão para descontinuação foi atribuída a efeitos adversos. Os resultados permitem concluir pela eficácia contraceptiva, bom controle de ciclo, tolerabilidade e bem-estar associados ao uso do contraceptivo de baixa dose contendo gestodeno e etinilestradiol em mulheres acima de 35 anos.