Coil or Plug-Assisted Ethylene Vinyl Alcohol Copolymer (EVOH) Thoracic Duct Embolization in the Treatment of Postoperative Chylothorax.

Eleven patients (5 men, 6 women) with post-operative thoracic duct injuries and high output chylothorax were treated with thoracic duct embolization (TDE). Six patients underwent intraprocedural thoracic duct ligation at the time of original procedure. In all cases, the pleural fluid demonstrated high triglyceride levels (414 mg/dL; interquartile range [IQR], 345 mg/dL). Median daily (IQR) chest tube outputs before and after TDE were 900 mL (1,200 mL) and 325 mL (630 mL), respectively. Coil- or plug-assisted ethylene vinyl alcohol (EVOH) copolymer was used as embolic agent in all patients. Technical and clinical success rates were 100% and 82%, respectively. Nontarget venous embolization of EVOH copolymer was not identified on subsequent imaging.

Increased nurses' anxiety disorder during the COVID-19 outbreak.

BACKGROUND: The rapid outbreak of COVID-19 at the beginning of 2020 in the world has put severe physical and psychological pressure on the medical staff of hospitals involved in the care of patients with COVID-19 to the point of risk of PTSD. There was. The aim of this study was to investigate the relationship between the prevalence of COVID-19 and nurses' anxiety disorder. METHODS: This review study was conducted by library method. RESULTS: As is well known and mentioned everywhere in cyberspace, nurses have lost their mental health and become very anxious during the COVID-19. Serious spread of traumatic psychiatric symptoms in the current situation can lead to damage to the health system. CONCLUSIONS: The need to care for nurses to relieve fatigue for several months and inject hope and motivation into this group should be understood, But due to the economic situation of the country, unfortunately, the fulfillment of the promises has been delayed, which we hope will be fulfilled soon; Although the delay will certainly not prevent nurses from properly caring for patients, but resolving nurses 'livelihood problems should also be a priority on the authorities' agenda.

The Association Between Risk Behaviors and Vaping Among Youth in New Mexico.

CONTEXT: Electronic-cigarette use, or vaping, among youth has increased substantially in recent years. Tobacco smoking shows a strong association with other risk behaviors, but the association between vaping and other risk behaviors has rarely been explored. We examine the relationship between youth vaping and substance use, risky driving behaviors, and lack of bicycle helmet use. PROGRAM: Data from the 2015 and 2017 New Mexico Youth Risk and Resiliency Survey were analyzed to evaluate the association between the use of e-cigarettes and other youth risk behaviors. Study participants were high school students, grades 9 to 12. Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI). EVALUATION: A majority of students reported ever using e-cigarettes (54%). In 2015, e-cigarette users were more likely than nonusers to be Hispanic (65% vs 54%, P ≤ .001) and 16 years of age or older (58% vs 42%, P = .018). We found strong, statistically significant associations between e-cigarette use and not wearing a bicycle helmet (OR = 2.62, 95% CI: 1.95-3.51), texting while driving (OR = 2.18, 95% CI: 1.79-2.66), driving after drinking (OR = 2.95, 95% CI: 1.61-5.40), current marijuana use (OR = 6.38, 95% CI: 4.65-8.76), current painkiller use (OR = 2.47, 95% CI: 1.63-3.77), and current heroin use (OR = 0.15, 95% CI: 0.06-0.33). Driving after drinking was not significantly associated with e-cigarette use in 2017. DISCUSSION: E-cigarette use is associated with multiple other risk behaviors among youth. Further research should focus on environmental and policy efforts to reduce access to e-cigarettes by youth as well as interventions that address the underlying causes of the constellation of risk behaviors.

Merging Orthovoltage X-Ray Minibeams spare the proximal tissues while producing a solid beam at the target.

Conventional radiation therapy of brain tumors often produces cognitive deficits, particularly in children. We investigated the potential efficacy of merging Orthovoltage X-ray Minibeams (OXM). It segments the beam into an array of parallel, thin (~0.3 mm), planar beams, called minibeams, which are known from synchrotron x-ray experiments to spare tissues. Furthermore, the slight divergence of the OXM array make the individual minibeams gradually broaden, thus merging with their neighbors at a given tissue depth to produce a solid beam. In this way the proximal tissues, including the cerebral cortex, can be spared. Here we present experimental results with radiochromic films to characterize the method's dosimetry. Furthermore, we present our Monte Carlo simulation results for physical absorbed dose, and a first-order biologic model to predict tissue tolerance. In particular, a 220-kVp orthovoltage beam provides a 5-fold sharper lateral penumbra than a 6-MV x-ray beam. The method can be implemented in arc-scan, which may include volumetric-modulated arc therapy (VMAT). Finally, OXM's low beam energy makes it ideal for tumor-dose enhancement with contrast agents such as iodine or gold nanoparticles, and its low cost, portability, and small room-shielding requirements make it ideal for use in the low-and-middle-income countries.

Endonasal transsphenoidal surgery and multimodality treatment for giant pituitary adenomas.

OBJECTIVE: Giant pituitary adenomas (> or =40 mm) pose a major management challenge. We describe the experience of a single surgeon and a dedicated neuro-endocrine team with multimodality treatment of these tumours in three specialized institutions. DESIGN: Retrospective data set analyses. PATIENTS: Fifty-one consecutive patients with a giant adenoma (39 endocrine-inactive, 12 endocrine-active; mean tumour diameter 45 mm) treated over 10 years by an endonasal transsphenoidal approach were included. All patients had surgical resection followed by radiotherapy and/or medical therapy as judged necessary. MEASUREMENTS: Hormonal and visual status, extent of resection, tumour control rates, complications and use of medical and radiotherapy were evaluated. RESULTS: Surgery resulted in gross total, near total and subtotal removal in21 (41%), 10 (20%) and 20 (39%) patients respectively. Complete tumour removal was associated with absence of cavernous sinus invasion (P < 0.001). Long-term endocrine function improved in 49% of patients and new endocrinopathy occurred in 14.6%; 76% required long-term hormone replacement therapy. Vision improved in 81.5% of the patients and there was no visual worsening. At the last follow up (median 30 months), tumour control was achieved in 96% of patients: 59% with surgery alone, 20% with surgery plus focussed radiotherapy, 18% with surgery and medical therapy and two with all three modalities. CONCLUSIONS: Endonasal surgery provides effective initial treatment for patients with giant adenomas. Multimodality therapy was needed in almost 50% of patients and this rate will likely increase with longer follow up. Close collaboration of neurosurgeons with endocrinologists and radiation oncologists is essential for optimal treatment of patients with these challenging tumours.

Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas.

OBJECTIVE: Endonasal and supraorbital "eyebrow" craniotomies are increasingly being used to remove craniopharyngiomas and tuberculum sellae meningiomas. Herein, we assess the relative advantages, disadvantages, and selection criteria of these 2 keyhole approaches. METHODS: All consecutive patients who had endonasal or supraorbital removal of a craniopharyngioma or tuberculum sellae meningioma were analyzed. RESULTS: Of 43 patients, 22 had a craniopharyngioma (18 endonasal, 4 supraorbital), and 21 had a meningioma (12 endonasal, 7 supraorbital, 2 both routes); 33% had prior surgery. Craniopharyngiomas were primarily retrochiasmal in location in 78% of endonasal cases versus 25% of supraorbital cases (P = 0.08). Meningiomas were larger when approached by the supraorbital route versus the endonasal route (33 +/- 10 versus 25 +/- 8 mm, respectively; P = 0.008). Endoscopy was used in 84% of endonasal approaches and in 31% of supraorbital approaches (P = 0.001). Of patients having first-time surgery for a craniopharyngioma (n = 14) or meningioma (n = 15), total/near total removal was achieved in 83% and 80% of patients by the endonasal route and in 50% and 80% of patients by the supraorbital route, respectively. Vision improved in 87% and 70% of patients who had surgery by an endonasal versus supraorbital route, respectively (P = 0.3). Visual deterioration occurred in 2 patients with meningiomas, 1 by endonasal (7%), and 1 by supraorbital (11%) removal. The endonasal approach was associated with a higher rate of postoperative cerebrospinal fluid leaks (16 versus 0%; P = 0.3), 4 of 5 of which occurred in patients with meningioma. CONCLUSION: The endonasal route is preferred for removal of most retrochiasmal craniopharyngiomas, whereas the supraorbital route is recommended for meningiomas larger than 30 to 35 mm or with growth beyond the supraclinoid carotid arteries. For smaller midline tumors, either approach can be used, depending on surgeon experience and tumor anatomy. Compared with traditional craniotomies, the major limitation of both approaches is a narrow surgical corridor. The endonasal approach has the added challenges of restricted lateral suprasellar access, a greater need for endoscopy, and a more demanding cranial base repair.

The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience.

THE DIRECT ENDONASAL transsphenoidal approach to the sella with the operating microscope was initially described more than 20 years ago. Herein, we describe the technique, its evolution, and lessons learned over a 10-year period for treating pituitary adenomas and other parasellar pathology. From July 1998 to January 2008, 812 patients underwent a total of 881 operations for a pituitary adenoma (n = 605), Rathke's cleft cyst (n = 59), craniopharyngioma (n = 26), parasellar meningioma (n = 23), chordoma (n = 18), or other pathological condition (n = 81). Of these, 118 operations (13%) included an extended approach to the suprasellar, infrasellar/clival, or cavernous sinus regions. Endoscopic assistance was used in 163 cases (19%) overall, including 36% of the last 200 cases in the series and 18 (72%) of the last 25 extended endonasal cases. Surgical complications included 19 postoperative cerebrospinal fluid leaks (2%), 6 postoperative hematomas (0.7%), 4 carotid artery injuries (0.4%), 4 new permanent neurological deficits (0.4%), 3 cases of bacterial meningitis (0.3%), and 2 deaths (0.2%). The overall complication rate was higher in the first 500 cases in the series and in extended approach cases. Major technical modifications over the 10-year period included increased use of shorter (60-70 mm) endonasal speculums for greater instrument maneuverability and visualization, the micro-Doppler probe for cavernous carotid artery localization, endoscopy for more panoramic visualization, and a graded cerebrospinal fluid leak repair protocol. These changes appear to have collectively and incrementally made the approach safer and more effective. In summary, the endonasal approach provides a minimally invasive route for removal of pituitary adenomas and other parasellar tumors.

Pituitary hormonal loss and recovery after transsphenoidal adenoma removal.

OBJECTIVE: Transsphenoidal adenomectomy carries the possibility of new pituitary failure and recovery. Herein, we present rates and determinants of postoperative hormonal status. METHODS: All consecutive patients who underwent endonasal transsphenoidal adenoma removal over an 8-year period were analyzed. Those with previous sellar radiotherapy were excluded. Pre- and postoperative hormonal status (at least 3 mo after surgery) were determined and correlated with clinical parameters using a multivariate statistical model. RESULTS: Of 444 patients (median age 45 years, 75% macroadenoma, 19% with multiple operations), 9 had preoperative panhypopituitarism. Of the remaining 435 patients, new hypopituitarism occurred in 5.5% of patients (anterior loss in 5%; permanent diabetes insipidus in 2.1%; including 2 patients who had total hypophysectomy). Of 346 patients with preoperative hormonal dysfunction, 170 (49%) had improved function. "Stalk compression" hyperprolactinemia resolved in 73% of 133 patients; recovery of at least 1 other anterior axis (excluding isolated hypogonadism associated with "stalk compression" hyperprolactinemia) occurred in 24% of 209 patients. Multivariate analysis showed that new hypopituitarism was most strongly associated with larger tumor diameter (P = 0.04). Of 223 patients with an endocrine-inactive adenoma, new hypopituitarism was seen in 0, 7.2, and 13.6% of patients with tumor diameters of <20, 20 to 29, and >or=30 mm, respectively (P = 0.005). Multivariate analysis revealed that resolution of hypopituitarism was related to younger age (39 versus 52 years, P < 0.0001), absence of an intraoperative cerebrospinal fluid leak and, in patients with an endocrine-inactive adenoma, absence of systemic hypertension (24% versus 6%, P = 0.009). CONCLUSION: After transsphenoidal adenomectomy, new unplanned hypopituitarism occurs in approximately 5% of patients, whereas improved hormonal function occurs in 50% of patients. The likelihood of new hormonal loss or recovery appears to depend on several factors. New hypopituitarism occurs most commonly in patients with tumors larger than 20 mm in size, whereas hormonal recovery is most likely to occur in younger, nonhypertensive patients and those without an intraoperative cerebrospinal fluid leak.

A short trapezoidal speculum for suprasellar and infrasellar exposure in endonasal transsphenoidal surgery.

OBJECTIVE: A key limitation of the transsphenoidal approach for suprasellar and infrasellar lesions is restricted exposure. Microscope and endoscope-assisted procedures have traditionally used an oval-shaped speculum, the distal end of which restricts superior and inferior visualization. To improve visualization and use of the endoscope, shorter specula, with a trapezoidal distal end, were designed. METHODS: The new specula have a working length of 60 mm. The proximal 20-mm segment is oval-shaped to conform to the nostril; the middle 20-mm segment has vertically oriented blades; and the distal 20-mm segment transitions to a trapezoidal orientation, with the distal blades angled 15 degrees upward and outward on the suprasellar speculum, or 15 degrees downward and outward on the infrasellar speculum. Both specula have a 5-degree distal outward flare. The upward-angled trapezoidal 60-mm speculum was compared with 70- and 80-mm oval specula in a transsphenoidal clay model. A pen light was projected from the nasal speculum end to a target 100 mm away using a blade opening width of 16 mm. Line drawings were made to quantify the impact of speculum length on the horizontal angle of exposure. The clinical utility of the trapezoidal specula was also assessed. RESULTS: In the model, the 60-mm upward-angled trapezoidal speculum yielded a surface area illumination of 759 mm, as compared with 579 and 432 mm with the 70-and 80-mm oval specula, an increase in exposure of 31 and 76%, respectively. In the line drawings, the 60-mm speculum provided a horizontal angle of exposure of 30 degrees, as compared with 26 and 23 degrees for the 70- and 80-mm specula, an increase of 17 and 33%, respectively. In patients, provided sufficient mucosa and bone are removed from the posterior nasal cavity, the trapezoidal specula provide an expanded working volume that facilitates endoscopy. CONCLUSION: Short upward- or downward-angled trapezoidal endonasal specula increase parasellar surface area exposure and the horizontal angle of exposure. Initial clinical experience suggests that reducing the speculum length and eliminating the distal curved blades result in greater instrument maneuverability and enhanced visibility for removing parasellar tumors.

Pituitary function after endonasal surgery for nonadenomatous parasellar tumors: Rathke's cleft cysts, craniopharyngiomas, and meningiomas.

BACKGROUND: Transsphenoidal surgery for parasellar nonadenomatous lesions has the possibility to either improve or worsen pituitary hormonal function. Herein we present the rates and risk factors of new hormonal failure and recovery in patients undergoing surgery for either an RCC, craniopharyngioma, or tuberculum sella meningioma. METHODS: All consecutive patients treated over an 8-year period by endonasal surgery for an RCC, craniopharyngioma, or tuberculum sella meningioma were analyzed. Patients treated with prior sellar radiotherapy were excluded. Preoperative and postoperative pituitary hormonal status was determined. Patient characteristics, tumor size, intraoperative and postoperative events, and extent of tumor resection were correlated with new or resolved hypopituitarism. RESULTS: In total, 50 patients with an RCC, 18 with a craniopharyngioma and 13 with tuberculum sellae meningioma, were analyzed. New anterior pituitary failure and permanent DI occurred as follows: in RCCs, 6% and 2%; in craniopharyngiomas, 31% and 39%; and in meningiomas, 9% and 0%. Overall, improved hormonal function occurred in 57% of patients with an RCC including recovery of one or more anterior axes in 9 (41%) of 22 patients and resolution of hyperprolactinemia in 12 (67%) of 18 patients; no patients with a craniopharyngioma or meningioma had resolution of hypopituitarism. Younger age was predictive of hormonal recovery in patients with an RCC (P = .026). CONCLUSIONS: New hypopituitarism after transsphenoidal surgery occurs in approximately one third of patients with a craniopharyngioma and in less than 10% of patients with an RCC or suprasellar meningioma. Hormonal function improves in the majority of patients undergoing drainage of an RCC but is unlikely to occur after removal of a craniopharyngioma or suprasellar meningioma.

Endonasal microscopic removal of clival chordomas.

INTRODUCTION: Clival chordomas have traditionally been removed using a variety of anterior and lateral skull base approaches. Herein, we evaluate the outcomes of patients who underwent an extended endonasal transsphenoidal removal of a clival chordoma. METHOD: All consecutive patients with a clival chordoma treated using an endonasal microscope approach were identified. In 8 cases, frameless surgical navigation was used, and in 4 cases, endoscopic assistance was used. Patients treated with prior radiotherapy were excluded. RESULT: Over 5 years, 18 procedures were performed on 14 patients (7 females; mean age, 47 years). Patients were followed from 3 to 58 months (median, 20 months). Mean tumor diameter was 32 +/- 17 mm; 7 (50%) patients had intradural extension. Postoperative MRIs after the initial operation showed gross total, near-total (>90%), and subtotal resection in 43%, 43%, and 14% of patients, respectively. Use of the endoscope was associated with gross total or near-total tumor removal in 4 of 4 cases. Tumor regrowth occurred in 2 (14%) cases 10 and 12 months after the initial surgery and before radiotherapy. Two patients had multiple operations, in one as a planned staged operation, and in the other, 3 additional debulkings were performed despite an initial gross total removal. Nine patients, all with CS invasion, had subsequent stereotactic radiation. Of 10 patients with cranial neuropathy, 80% improved or resolved including 75% and 67% of sixth and fifth CN palsies, respectively. Complications included one each of adrenal insufficiency and chemical meningitis. There were no CSF leaks or new neurological deficits. CONCLUSION: In this small series with relatively short follow-up, endonasal microscopic removal of clival chordomas proved safe and elfective with gross total or near-total removal in 86% of patients and improvement of cranial neuropathy in 80% of patients. Endoscopy for aiding tumor removal and assessing completeness of resection, as well as surgical navigation, are recommended for all cases.

Long-term outcome of superficial temporal artery-middle cerebral artery bypass for patients with moyamoya disease in the US.

OBJECT: The authors report the long-term results of a series of direct superficial temporal artery-middle cerebral artery (STA-MCA) bypass procedures in patients with moyamoya disease from the western US. METHODS: All patients with moyamoya disease treated at the University of Washington from 1990 through 2004 (39 patients) were included in this study. Patients underwent pre- and postoperative evaluation of cerebral perfusion dynamics. Surgical revascularization procedures were performed in all patients with impaired cerebral blood flow (CBF) findings. RESULTS: The mean age of patients at diagnosis was 34 years (range 10-55 years). All 39 patients had impaired CBF and/or vasomotor reserve and underwent revascularization procedures: 26 patients underwent bilateral operations, 13 unilateral (65 total procedures). An STA-MCA bypass was technically possible in 56 procedures (86.2%); saphenous vein interposition grafts were required in 3 procedures (4.6%); encephaloduroarteriosynangiosis was performed in 6 procedures (9.2%). Three patients died due to postoperative complications, yielding a procedure-related mortality rate of 4.61%, and 8 experienced non-life threatening complications (for a procedure-related rate of 12.3%). Long-term follow-up appeared to indicate a reduction in further ischemic events in surviving patients compared with the natural history. Cerebral perfusion dynamics improved postoperatively in all 36 surviving patients. CONCLUSIONS: Moyamoya disease may differ in the US and Asia, and STA-MCA bypass procedures may prevent future ischemic events in patients with this condition.

Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery.

OBJECTIVE: A graded approach to cerebrospinal fluid (CSF) leak repair after transsphenoidal surgery is presented. METHODS: Patients undergoing endonasal tumor removal during an 8-year period were reviewed. Intraoperative CSF leaks were classified as Grade 0, no leak observed; Grade 1, small leak without obvious diaphragmatic defect; Grade 2, moderate leak; or Grade 3, large diaphragmatic/dural defect. Cranial base repair was tailored to the leak grade as Grade 0, collagen sponge; Grade 1, two-layered collagen sponge repair with intrasellar titanium mesh buttress; Grade 2, intrasellar and sphenoid sinus fat grafts with collagen sponge overlay and titanium buttress; and Grade 3, same as Grade 2 with CSF diversion in most cases. A provocative tilt test was performed before patient discharge to assess the integrity of the CSF leak repair. Protocol modifications adopted in 2003 included an intrasellar fat graft in Grade 1 leaks with a large intrasellar dead space, frequent use of BioGlue (CryoLife, Inc., Atlanta, GA) in Grade 1, 2, and 3 leaks, and CSF diversion for all Grade 3 leaks. RESULTS: Among 668 cases in 620 patients (475 pituitary adenomas and 145 other lesions), an intraoperative CSF leak was observed in 57% of the cases: 32.5% Grade 1, 15% Grade 2, and 8.7% Grade 3. Postoperative repair failures occurred in 17 cases (2.5%), including 0.7, 3, 1, and 12% of Grade 0, 1, 2, and 3 CSF leaks, respectively. Bacterial meningitis occurred in three patients (0.45%). After protocol modifications in 2003, repair failures decreased from 4 to 1.2% (P = 0.02). CONCLUSION: A graded repair approach to CSF leaks in transsphenoidal surgery avoids tissue grafts and CSF diversion in more than 60% of patients. Protocol modifications adopted in the last 340 cases have reduced the failure rate to 1% overall and 7% for Grade 3 leaks. Provocative tilt testing before patient discharge is helpful in the timely diagnosis of postoperative CSF leaks.