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1.
Proc Natl Acad Sci U S A ; 120(4): e2216614120, 2023 01 24.
Artigo em Inglês | MEDLINE | ID: mdl-36649414

RESUMO

Why do people share misinformation on social media? In this research (N = 2,476), we show that the structure of online sharing built into social platforms is more important than individual deficits in critical reasoning and partisan bias-commonly cited drivers of misinformation. Due to the reward-based learning systems on social media, users form habits of sharing information that attracts others' attention. Once habits form, information sharing is automatically activated by cues on the platform without users considering response outcomes such as spreading misinformation. As a result of user habits, 30 to 40% of the false news shared in our research was due to the 15% most habitual news sharers. Suggesting that sharing of false news is part of a broader response pattern established by social media platforms, habitual users also shared information that challenged their own political beliefs. Finally, we show that sharing of false news is not an inevitable consequence of user habits: Social media sites could be restructured to build habits to share accurate information.


Assuntos
Comunicação , Mídias Sociais , Humanos , Disseminação de Informação , Resolução de Problemas
2.
N Engl J Med ; 383(27): 2616-2627, 2020 12 31.
Artigo em Inglês | MEDLINE | ID: mdl-33326713

RESUMO

BACKGROUND: Chronic subdural hematoma is a common neurologic disorder that is especially prevalent among older people. The effect of dexamethasone on outcomes in patients with chronic subdural hematoma has not been well studied. METHODS: We conducted a multicenter, randomized trial in the United Kingdom that enrolled adult patients with symptomatic chronic subdural hematoma. The patients were assigned in a 1:1 ratio to receive a 2-week tapering course of oral dexamethasone, starting at 8 mg twice daily, or placebo. The decision to surgically evacuate the hematoma was made by the treating clinician. The primary outcome was a score of 0 to 3, representing a favorable outcome, on the modified Rankin scale at 6 months after randomization; scores range from 0 (no symptoms) to 6 (death). RESULTS: From August 2015 through November 2019, a total of 748 patients were included in the trial after randomization - 375 were assigned to the dexamethasone group and 373 to the placebo group. The mean age of the patients was 74 years, and 94% underwent surgery to evacuate their hematomas during the index admission; 60% in both groups had a score of 1 to 3 on the modified Rankin scale at admission. In a modified intention-to-treat analysis that excluded the patients who withdrew consent for participation in the trial or who were lost to follow-up, leaving a total of 680 patients, a favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group (difference, -6.4 percentage points [95% confidence interval, -11.4 to -1.4] in favor of the placebo group; P = 0.01). Among the patients with available data, repeat surgery for recurrence of the hematoma was performed in 6 of 349 patients (1.7%) in the dexamethasone group and in 25 of 350 patients (7.1%) in the placebo group. More adverse events occurred in the dexamethasone group than in the placebo group. CONCLUSIONS: Among adults with symptomatic chronic subdural hematoma, most of whom had undergone surgery to remove their hematomas during the index admission, treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Dex-CSDH ISRCTN number, ISRCTN80782810.).


Assuntos
Dexametasona/uso terapêutico , Glucocorticoides/uso terapêutico , Hematoma Subdural Crônico/tratamento farmacológico , Administração Oral , Idoso , Terapia Combinada , Dexametasona/administração & dosagem , Dexametasona/efeitos adversos , Pessoas com Deficiência , Feminino , Glucocorticoides/administração & dosagem , Glucocorticoides/efeitos adversos , Hematoma Subdural Crônico/complicações , Hematoma Subdural Crônico/mortalidade , Hematoma Subdural Crônico/cirurgia , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Reoperação/estatística & dados numéricos , Índice de Gravidade de Doença , Resultado do Tratamento
3.
Acta Neurochir (Wien) ; 165(2): 451-459, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36220949

RESUMO

PURPOSE: Due to the risk of intracranial aneurysm (IA) recurrence and the potential requirement for re-treatment following endovascular treatment (EVT), radiological follow-up of these aneurysms is necessary. There is little evidence to guide the duration and frequency of this follow-up. The aim of this study was to establish the current practice in neurosurgical units in the UK and Ireland. METHODS: A survey was designed with input from interventional neuroradiologists and neurosurgeons. Neurovascular consultants in each of the 30 neurosurgical units providing a neurovascular service in the UK and Ireland were contacted and asked to respond to questions regarding the follow-up practice for IA treated with EVT in their department. RESULTS: Responses were obtained from 28/30 (94%) of departments. There was evidence of wide variations in the duration and frequency of follow-up, with a minimum follow-up duration for ruptured IA that varied from 18 months in 5/28 (18%) units to 5 years in 11/28 (39%) of units. Young patient age, previous subarachnoid haemorrhage and incomplete IA occlusion were cited as factors that would prompt more intensive surveillance, although larger and broad-necked IA were not followed-up more closely in the majority of departments. CONCLUSIONS: There is a wide variation in the radiological follow-up of IA treated with EVT in the UK and Ireland. Further standardisation of this aspect of patient care is likely to be beneficial, but further evidence on the behaviour of IA following EVT is required in order to inform this process.


Assuntos
Aneurisma Roto , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Hemorragia Subaracnóidea , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Seguimentos , Irlanda , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/cirurgia , Embolização Terapêutica/métodos , Aneurisma Roto/cirurgia , Reino Unido , Resultado do Tratamento
4.
Neurosurg Focus ; 52(3): E5, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-35231895

RESUMO

OBJECTIVE: Delayed ischemic neurological deficit (DIND) is seen as a clinical manifestation of cerebral vasospasm and is a significant cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Currently, the standard of care for DIND prevention in patients who have sustained aSAH is prophylactic nimodipine therapy and ensuring adequate fluid intake, alongside other treatments such as bowel care. Osmotic laxatives trap water within the bowel lumen to accelerate the transport of the gut contents through the bowel. Given the potential for DIND secondary to cerebral vasospasm, it is perhaps counterintuitive that gastrointestinal fluid loss and use of osmotic laxatives are not commonly considered in many aSAH management protocols. METHODS: A retrospective case note analysis was performed for all adult patients (aged > 16 years) admitted to the Department of Neurosurgery at Leeds General Infirmary with a diagnosis of aSAH between August 2019 and September 2020. RESULTS: A total of 105 patients were included, 62% of whom were female, with a mean and median age of 54 years (range 24-84 years). Diarrhea was noted in 12 patients (11.4%), 58% of whom subsequently developed DIND (OR 15.30, CI 3.92-59.14; p = 0.0001). All patients received osmotic laxatives (97% having received ≥ 2 laxative agents). CONCLUSIONS: Patients with aSAH who subsequently developed diarrhea had significantly increased odds of developing DIND. Enteral volume loss due to osmotic laxative use is a potential risk factor for DIND after aSAH.


Assuntos
Isquemia Encefálica , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Infarto Cerebral/complicações , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/cirurgia , Vasoespasmo Intracraniano/etiologia , Adulto Jovem
5.
Neurosurg Focus ; 52(3): E4, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-35231894

RESUMO

OBJECTIVE: Recent evidence has suggested that an admission neutrophil-to-lymphocyte ratio (NLR) of ≥ 5.9 predicts delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH). The primary aims of this study were to assess reproducibility and to ascertain the predictive ability of NLR on subsequent days postictus. Secondary aims included identification of additional inflammatory markers. METHODS: A single-center, retrospective study of all patients aged ≥ 18 years with aSAH between May 2014 and July 2018 was performed. Patient characteristics, DCI incidence, operative features, and outcomes (on discharge and at 3 months postictus) were recorded. C-reactive protein (CRP) and full blood count differentials were recorded on admission and through day 8 postictus or at discharge. In total, 403 patients were included in the final analysis. RESULTS: Ninety-six patients (23.8%) developed DCI with a median time from ictus of 6 days (IQR 3.25-8 days). A platelet-to-lymphocyte ratio (PLR) cutoff ≥ 157 and CRP cutoff ≥ 27 was used in our cohort. In a multiple binary logistic regression model, after controlling for known DCI predictors, day 2 NLR ≥ 5.9 (OR 2.194, 95% CI 1.099-4.372; p = 0.026), day 1 PLR ≥ 157 (OR 2.398, 95% CI 1.1072-5.361; p = 0.033), day 2 PLR ≥ 157 (OR 2.676, 95% CI 1.344-5.329; p = 0.005), and CRP ≥ 27 on days 3, 4, and 5 were predictive of DCI. CONCLUSIONS: The results of this study have confirmed the association between NLR and DCI and have demonstrated the predictive potential of PLR and CRP, suggesting that NLR and PLR at day 2, and CRP from day 3 onward, may be better predictors of DCI than those measurements at the time of ictus.


Assuntos
Isquemia Encefálica , Hemorragia Subaracnóidea , Adolescente , Isquemia Encefálica/etiologia , Humanos , Linfócitos/metabolismo , Neutrófilos/metabolismo , Reprodutibilidade dos Testes , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações
6.
Acta Neurochir (Wien) ; 164(3): 771-779, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-33956233

RESUMO

BACKGROUND: There is limited evidence to direct the management of unruptured intracranial aneurysms. Models extrapolated from existing data have been proposed to guide treatment recommendations. The aim of this study is to assess whether a consensus-based treatment score (UIATS) or rupture rate estimation model (PHASES) can be used to benchmark UK multi-disciplinary team (MDT) practice. METHODS: Prospective data was collected on a consecutive series of all patients with unruptured intracranial aneurysms (UIAs) presenting to a major UK neurovascular centre between 2012 and 2015. The agreement between the UIATS and PHASES scores, and their sensitivity and specificity in predicting the real-world MDT outcome were calculated and compared. RESULTS: A total of 366 patients (456 aneurysms) were included in the analysis. The agreement between UIATS and MDT recommendation was low (weighted kappa 0.26 [95% CI 0.19, 0.32]); sensitivity and specificity were also low at 36% and 52% respectively. Groups that the MDT allocated to treatment, equipoise or no treatment had significantly different PHASES scores (p = 0.004). There was no significant difference between the two scores when predicting patients for whom MDT outcome was to recommend aneurysm treatment, but the UIATS score was superior in predicting patients who received an MDT recommendation of 'treatment-equipoise', or 'not-for-treatment' (AUC of 0.73 compared to 0.59 for PHASES). CONCLUSIONS: The models studied failed to agree with the consensus view of multi-disciplinary team in a major neurovascular centre. We conclude that decision support tools such as the UIATS and PHASES scores should not be blindly introduced in respective institutions without prior internal validation, as they may not represent the local reality.


Assuntos
Aneurisma Roto , Aneurisma Intracraniano , Aneurisma Roto/terapia , Estudos de Coortes , Humanos , Aneurisma Intracraniano/diagnóstico , Aneurisma Intracraniano/terapia , Estudos Prospectivos , Estudos Retrospectivos
7.
Acta Neurochir (Wien) ; 164(2): 507-515, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-35039955

RESUMO

PURPOSE: To evaluate the distribution and impact of ABO blood group on the baseline characteristics and clinical outcomes of patients presenting with aneurysmal subarachnoid haemorrhage (aSAH). METHODS: Retrospective, single-centre study of patients admitted to a neurosurgical department in the UK, with a diagnosis of spontaneous subarachnoid haemorrhage between May 2014 and January 2020. Patients were categorised by ABO blood type and by Rhesus status. Clinical outcomes such as initial bleeding, rebleeding, delayed cerebral ischaemia (DIND) and venous thromboembolism were analysed in relation to the size of their association with ABO blood type. Hospital mortality rate, Glasgow Outcome Score (GOS) - at discharge and 3 months post-ictus, requirement for ventriculoperitoneal shunt insertion, discharge destination and inpatient length of stay were also considered. RESULTS: Four-hundred twelve adult patients admitted with aSAH were included in our analysis. The distribution of ABO group or Rhesus status in our cohort did not differ significantly from the general population in the UK. Blood group A patients had a significantly increased risk of developing DIND, compared with non-blood group A patients (OR, 1.88 [95% CI: 1.10-3.21]). CONCLUSIONS: ABO blood type appears to influence aSAH sequelae. Blood group A patients are at highest risk of DIND following aSAH.


Assuntos
Isquemia Encefálica , Hemorragia Subaracnóidea , Sistema ABO de Grupos Sanguíneos , Humanos , Projetos Piloto , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações
8.
Br J Neurosurg ; 30(3): 351-2, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26742421

RESUMO

The role of neuronavigation in tumour surgery is well established. We present an innovative use for this software, as a tool to compare ventricular size between serial sets of cranial imaging. We conclude that neuronavigation software is potentially a powerful diagnostic tool that should not be overlooked when making comparative assessments between scans.


Assuntos
Ventrículos Cerebrais/cirurgia , Hidrocefalia/cirurgia , Neuronavegação , Crânio/cirurgia , Software , Terapia Assistida por Computador , Humanos , Hidrocefalia/diagnóstico , Neuronavegação/métodos , Terapia Assistida por Computador/métodos , Derivação Ventriculoperitoneal/métodos
9.
Health Technol Assess ; 28(12): 1-122, 2024 03.
Artigo em Inglês | MEDLINE | ID: mdl-38512045

RESUMO

Background: Chronic subdural haematoma is a collection of 'old blood' and its breakdown products in the subdural space and predominantly affects older people. Surgical evacuation remains the mainstay in the management of symptomatic cases. Objective: The Dex-CSDH (DEXamethasone in Chronic SubDural Haematoma) randomised trial investigated the clinical effectiveness and cost-effectiveness of dexamethasone in patients with a symptomatic chronic subdural haematoma. Design: This was a parallel, superiority, multicentre, pragmatic, randomised controlled trial. Assigned treatment was administered in a double-blind fashion. Outcome assessors were also blinded to treatment allocation. Setting: Neurosurgical units in the UK. Participants: Eligible participants included adults (aged ≥ 18 years) admitted to a neurosurgical unit with a symptomatic chronic subdural haematoma confirmed on cranial imaging. Interventions: Participants were randomly assigned in a 1 : 1 allocation to a 2-week tapering course of dexamethasone or placebo alongside standard care. Main outcome measures: The primary outcome was the Modified Rankin Scale score at 6 months dichotomised to a favourable (score of 0-3) or an unfavourable (score of 4-6) outcome. Secondary outcomes included the Modified Rankin Scale score at discharge and 3 months; number of chronic subdural haematoma-related surgical interventions undertaken during the index and subsequent admissions; Barthel Index and EuroQol 5-Dimension 5-Level utility index score reported at discharge, 3 months and 6 months; Glasgow Coma Scale score reported at discharge and 6 months; mortality at 30 days and 6 months; length of stay; discharge destination; and adverse events. An economic evaluation was also undertaken, during which the net monetary benefit was estimated at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year. Results: A total of 748 patients were included after randomisation: 375 were assigned to dexamethasone and 373 were assigned to placebo. The mean age of the patients was 74 years and 94% underwent evacuation of their chronic subdural haematoma during the trial period. A total of 680 patients (91%) had 6-month primary outcome data available for analysis: 339 in the placebo arm and 341 in the dexamethasone arm. On a modified intention-to-treat analysis of the full study population, there was an absolute reduction in the proportion of favourable outcomes of 6.4% (95% confidence interval 11.4% to 1.4%; p = 0.01) in the dexamethasone arm compared with the control arm at 6 months. At 3 months, the between-group difference was also in favour of placebo (-8.2%, 95% confidence interval -13.3% to -3.1%). Serious adverse events occurred in 60 out of 375 (16.0%) in the dexamethasone arm and 24 out of 373 (6.4%) in the placebo arm. The net monetary benefit of dexamethasone compared with placebo was estimated to be -£97.19. Conclusions: This trial reports a higher rate of unfavourable outcomes at 6 months, and a higher rate of serious adverse events, in the dexamethasone arm than in the placebo arm. Dexamethasone was also not estimated to be cost-effective. Therefore, dexamethasone cannot be recommended for the treatment of chronic subdural haematoma in this population group. Future work and limitations: A total of 94% of individuals underwent surgery, meaning that this trial does not fully define the role of dexamethasone in conservatively managed haematomas, which is a potential area for future study. Trial registration: This trial is registered as ISRCTN80782810. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/15/02) and is published in full in Health Technology Assessment; Vol. 28, No. 12. See the NIHR Funding and Awards website for further award information.


Chronic subdural haematoma is one of the most common conditions managed in adult neurosurgery and mainly affects older people. It is an 'old' collection of blood and blood breakdown products found on the surface of the brain. Surgery to drain the liquid collection is effective, with most patients improving. Given that inflammation is involved in the disease process, a commonly used steroid, dexamethasone, has been used alongside surgery or instead of surgery since the 1970s. However, there is no consensus or high-quality studies confirming the effectiveness of dexamethasone for the treatment of chronic subdural haematoma. This study was designed to determine the effectiveness of adding dexamethasone to the normal treatment for patients with a symptomatic chronic subdural haematoma. The benefit of adding dexamethasone was measured using a disability score called the Modified Rankin Scale, which can be divided into favourable and unfavourable outcomes. This was assessed at 6 months after entry into the study. In total, 748 adults with a symptomatic chronic subdural haematoma treated in neurosurgical units in the UK participated. Each participant had an equal chance of receiving either dexamethasone or a placebo because they were assigned randomly. Neither the patients nor the investigators knew who received dexamethasone and who received placebo. Most patients in both groups had an operation to drain the haematoma and experienced significant functional improvement at 6 months compared with their initial admission to hospital. However, patients who received dexamethasone had a lower chance than patients who received placebo of favourable recovery at 6 months. Specifically, 84% of patients who received dexamethasone had recovered well at 6 months, compared with 90% of patients who received placebo. There were more complications in the group that received dexamethasone. This trial demonstrates that adding dexamethasone to standard treatment reduced the chance of a favourable outcome compared with standard treatment alone. Therefore, this study does not support the use of dexamethasone in treating patients with a symptomatic chronic subdural haematoma.


Assuntos
Hematoma Subdural Crônico , Adulto , Humanos , Idoso , Hematoma Subdural Crônico/tratamento farmacológico , Hospitalização , Análise Custo-Benefício , Método Duplo-Cego , Dexametasona/uso terapêutico
10.
Transl Stroke Res ; 14(1): 94-99, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-35943718

RESUMO

Delayed cerebral ischaemia (DCI) is a significant complication of aneurysmal subarachnoid haemorrhage (aSAH) and is strongly associated with poorer outcome. The Alberta Stroke Program Early Computer Tomography (ASPECT) score is an established scoring tool, used in acute ischaemic stroke, to quantify early ischaemic changes on CT head scans. We aim to identify if ASPECT scoring correlates with functional outcome in DCI following aSAH. Retrospective case-control study. Inclusion criteria: admission to the Department of Neurosurgery at Leeds Teaching Hospitals NHS Trust (a tertiary neurosurgical centre in the United Kingdom) between 2014 and 2018, with a diagnosis of anterior circulation aneurysmal subarachnoid haemorrhage; as confirmed by initial CT scan and subsequent CT angiography or catheter digital subtraction angiography. Cases were those who developed DCI (n = 43) and controls were randomly selected from those who did not develop DCI (n = 46) but otherwise met the same inclusion criteria. The primary outcome measure was Glasgow Outcome Score (GOS): assessed at discharge and 3 months. ASPECT scores were calculated from non-contrast CT head scans by three researchers blinded to each other and clinical outcome. Spearman's rank correlation was used to calculate correlation between ASPECT scores and GOS. ASPECT score positively correlated with GOS in the cases both at discharge (Spearman rho 0.436, p = 0.003) and at 3 months (Spearman rho 0.431, p = 0.004). When corrected for Fisher grading, the adjusted odds ratio of having a high GOS with a low ASPECT score at discharge was OR 0.74 (95% CI 0.61-0.94, p = 0.003), and 3 months OR 0.73 (95% CI 0.59-0.91, p = 0.005). ASPECT score significantly correlates with clinical outcome in DCI post aSAH, even after correcting for Fisher grade. ASPECT scoring may identify patients at risk of poor outcome following DCI and represents a quick and reliable tool that aids in clinical decision-making and prognostication.


Assuntos
Isquemia Encefálica , Acidente Vascular Cerebral , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Humanos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico por imagem , Isquemia Encefálica/complicações , Estudos de Casos e Controles , Estudos Retrospectivos , Alberta , Acidente Vascular Cerebral/complicações , Infarto Cerebral/complicações , Tomografia Computadorizada por Raios X , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/complicações
11.
Acta Neurochir (Wien) ; 159(4): 603, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28111700
12.
Curr Opin Psychol ; 45: 101303, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35255413

RESUMO

Social media habits represent one of the most common - and controversial - forms of habitual behavior in contemporary society. In this brief article, we summarize the state of research on social media habits, along with their position within the technology habit literature. First, we review the wide range of positive and negative behaviors falling under the umbrella of "social media habits." Then, we deconstruct how a given social media habit can be viewed from five levels of analysis: platform, device, interface, behavior, and motor. Last, we anticipate how future researchers and designers will have the potential to detect (un)healthy habitual processes via digital tracking. As a whole, the article demonstrates the need to break apart the components of social media habits in order to clarify their implications for well-being.


Assuntos
Mídias Sociais , Hábitos , Humanos
13.
Br J Hosp Med (Lond) ; 81(12): 1-10, 2020 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-33377832

RESUMO

Radiological investigations are a powerful tool in the assessment of patients with intracranial vascular anomalies. 'Visual' assessment of neurovascular lesions is central to their diagnosis, monitoring, prognostication and management. Computed tomography and magnetic resonance imaging are the two principal non-invasive imaging modalities used in clinical practice for the assessment of the cerebral vasculature, but these techniques continue to evolve, enabling clinicians to gain greater insights into neurovascular pathology and pathophysiology. This review outlines both established and novel imaging modalities used in modern neurovascular practice and their clinical applications.


Assuntos
Imageamento por Ressonância Magnética , Neuroimagem/métodos , Neurocirurgia/métodos , Tomografia Computadorizada por Raios X , Humanos
15.
Sci Rep ; 9(1): 5885, 2019 04 10.
Artigo em Inglês | MEDLINE | ID: mdl-30971773

RESUMO

The Dex-CSDH trial is a randomised, double-blind, placebo-controlled trial of dexamethasone for patients with a symptomatic chronic subdural haematoma. The trial commenced with an internal pilot, whose primary objective was to assess the feasibility of multi-centre recruitment. Primary outcome data collection and safety were also assessed, whilst maintaining blinding. We aimed to recruit 100 patients from United Kingdom Neurosurgical Units within 12 months. Trial participants were randomised to a 2-week course of dexamethasone or placebo in addition to receiving standard care (which could include surgery). The primary outcome measure of the trial is the modified Rankin Scale at 6 months. This pilot recruited ahead of target; 100 patients were recruited within nine months of commencement. 47% of screened patients consented to recruitment. The primary outcome measure was collected in 98% of patients. No safety concerns were raised by the independent data monitoring and ethics committee and only five patients were withdrawn from drug treatment. Pilot trial data can inform on the design and resource provision for substantive trials. This internal pilot was successful in determining recruitment feasibility. Excellent follow-up rates were achieved and exploratory outcome measures were added to increase the scientific value of the trial.


Assuntos
Dexametasona/uso terapêutico , Hematoma Subdural Crônico/tratamento farmacológico , Dexametasona/efeitos adversos , Método Duplo-Cego , Esquema de Medicação , Hematoma Subdural Crônico/patologia , Humanos , Projetos Piloto , Efeito Placebo , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
16.
J Neurosurg ; : 1-7, 2018 Jun 08.
Artigo em Inglês | MEDLINE | ID: mdl-29882697

RESUMO

OBJECTIVEMost intracranial aneurysms are now treated by endovascular rather than by microsurgical procedures. There is evidence to demonstrate superior outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) treated by endovascular techniques. However, some cases continue to require microsurgery. The authors have examined the relationship between the number of aneurysms treated by microsurgery and outcome for patients undergoing treatment for aSAH at neurosurgical centers in England.METHODSThe Neurosurgical National Audit Programme (NNAP) database was used to identify aSAH cases and to provide associated 30-day mortality rates for each of the 24 neurosurgical centers in England. Data were compared for association by regression analysis using the Pearson product-moment correlation coefficient and any associations were tested for statistical significance using the one-way ANOVA test. The NNAP data were validated utilizing a second, independent registry: the British Neurovascular Group's (BNVG) National Subarachnoid Haemorrhage Database.RESULTSIncreasing numbers of microsurgical cases in a center are associated with lower 30-day mortality rates for all patients treated for aSAH, irrespective of treatment modality (Pearson r = 0.42, p = 0.04), and for patients treated for aSAH by endovascular procedures (Pearson r = 0.42, p = 0.04). The correlations are stronger if all (elective and acute) microsurgical cases are compared with outcome. The BNVG data validated the NNAP data set for patients with aSAH.CONCLUSIONSThere is a statistically significant association between local microsurgical activity and center outcomes for patients with aSAH, even for patients treated endovascularly. The authors postulate that the number of microsurgical cases performed may be a surrogate indicator of closer neurosurgical involvement in the overall management of neurovascular patients and of optimal case selection.

17.
J Neurosurg ; 130(1): 145-153, 2018 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-29521592

RESUMO

OBJECTIVE The aim of this study was to provide a comprehensive benchmark of 30-day ventriculoperitoneal (VP) shunt failure rates for a single institution over a 5-year study period for both adult and pediatric patients, to compare this with the results in previously published literature, and to establish factors associated with shunt failure. METHODS A retrospective database search was undertaken to identify all VP shunt operations performed in a single, regional neurosurgical unit during a 5-year period. Data were collected regarding patient age, sex, origin of hydrocephalus, and whether the shunt was a primary or secondary shunt. Operative notes were used to ascertain the type of valve inserted, which components of the shunt were adjusted/replaced (in revision cases), level of seniority of the most senior surgeon who participated in the operation, and number of surgeons involved in the operation. Where appropriate and where available, postoperative imaging was assessed for grade of shunt placement, using a recognized grading system. Univariate and multivariate models were used to establish factors associated with early (30-day) shunt failure. RESULTS Six hundred eighty-three VP shunt operations were performed, of which 321 were pediatric and 362 were adult. The median duration of postoperative follow-up for nonfailed shunts (excluding deaths) was 1263 days (range 525-2226 days). The pediatric 30-day shunt failure rates in the authors' institution were 8.8% for primary shunts and 23.4% for revisions. In adults, the 30-day shunt failure rates are 17.7% for primary shunts and 25.6% for revisions. In pediatric procedures, the number of surgeons involved in the operating theater was significantly associated with shunt failure rate. In adults, the origin of hydrocephalus was a statistically significant variable. Primary shunts lasted longer than revision shunts, irrespective of patient age. CONCLUSIONS A benchmark of 30-day failures is presented and is consistent with current national databases and previously published data by other groups. The number of surgeons involved in shunt operations and the origin of the patient's hydrocephalus should be described in future studies and should be controlled for in any prospective work. The choice of shunt valve was not a significant predictor of shunt failure. Most previous studies on shunts have concentrated on primary shunts, but the high rate of early shunt failure in revision cases (in both adults and children) is perhaps where future research efforts should be concentrated.


Assuntos
Hidrocefalia/cirurgia , Complicações Pós-Operatórias/epidemiologia , Derivação Ventriculoperitoneal/efeitos adversos , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Falha de Equipamento , Feminino , Humanos , Hidrocefalia/etiologia , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
18.
Trials ; 19(1): 670, 2018 12 04.
Artigo em Inglês | MEDLINE | ID: mdl-30514400

RESUMO

BACKGROUND: Chronic subdural haematoma (CSDH) is a common neurosurgical condition, typically treated with surgical drainage of the haematoma. However, surgery is associated with mortality and morbidity, including up to 20% recurrence of the CSDH. Steroids, such as dexamethasone, have been identified as a potential therapy for reducing recurrence risk in surgically treated CSDHs. They have also been used as a conservative treatment option, thereby avoiding surgery altogether. The hypothesis of the Dex-CSDH trial is that a two-week course of dexamethasone in symptomatic patients with CSDH will lead to better functional outcome at six months. This is anticipated to occur through reduced number of hospital admissions and surgical interventions. METHODS: Dex-CSDH is a UK multi-centre, double-blind randomised controlled trial of dexamethasone versus placebo for symptomatic adult patients diagnosed with CSDH. A sample size of 750 patients has been determined, including an initial internal pilot phase of 100 patients to confirm recruitment feasibility. Patients must be recruited within 72 h of admission to a neurosurgical unit and exclusions include patients already on steroids or with steroid contraindications, patients who have a cerebrospinal fluid shunt and those with a history of psychosis. The decision regarding surgical intervention will be made by the clinical team and patients can be included in the trial regardless of whether operative treatment is planned or has been performed. The primary outcome measure is the modified Rankin Scale (mRS) at six months. Secondary outcomes include the number of CSDH-related surgical interventions during follow-up, length of hospital stay, mRS at three months, EQ-5D at three and six months, adverse events, mortality and a health-economic analysis. DISCUSSION: This multi-centre trial will provide high-quality evidence as to the effectiveness of dexamethasone in the treatment of CSDH. This has implications for patient morbidity and mortality as well as a potential economic impact on the overall health service burden from this condition. TRIAL REGISTRATION: ISRCTN, ISRCTN80782810 . Registered on 7 November 2014. EudraCT, 2014-004948-35 . Registered on 20 March 2015. Dex-CSDH trial protocol version 3, 27 Apr 2017. This protocol was developed in accordance with the SPIRIT checklist. Available as a separate document on request.


Assuntos
Dexametasona/administração & dosagem , Glucocorticoides/administração & dosagem , Hematoma Subdural Crônico/tratamento farmacológico , Análise Custo-Benefício , Dexametasona/efeitos adversos , Dexametasona/economia , Método Duplo-Cego , Esquema de Medicação , Custos de Medicamentos , Glucocorticoides/efeitos adversos , Glucocorticoides/economia , Hematoma Subdural Crônico/diagnóstico , Hematoma Subdural Crônico/economia , Hematoma Subdural Crônico/mortalidade , Humanos , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Resultado do Tratamento , Reino Unido
19.
J Neurosurg ; 123(1): 153-60, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25699413

RESUMO

OBJECT: Neurosurgical patties are textile pads used during most neurosurgical operations to protect tissues, manage the fluid environment, control hemostasis, and aid tissue manipulation. Recent research has suggested that, contrary to their aim, patties adhere to brain tissue and cause damage during removal. This study aimed to characterize and quantify the degree of and consequences resulting from adhesion between neurosurgical patties and brain tissue. METHODS: Using a customized peel apparatus, the authors performed 90° peel tests on 5 patty products: Policot, Telfa, Americot, Delicot, and Ray-Cot (n = 247) from American Surgical Company. They tested 4 conditions: wet patty on glass (control), wet patty on wet brain peeled at 5 mm/sec (wet), dry patty on wet brain peeled at 5 mm/sec (dry), and wet patty on wet brain peeled at 20 mm/sec (speed). The interaction between patty and tissue was analyzed using peel-force traces and pre-peel histological analysis. RESULTS: Adhesion strength differed between patty products (p < 0.001) and conditions (p < 0.001). Adhesion strength was greatest for Delicot patties under wet (2.22 mN/mm) and dry (9.88 mN/mm) conditions. For all patties, damage at the patty-tissue interface was proportional to the degree of fiber contact. When patties were irrigated, mechanical adhesion was reduced by up to 550% compared with dry usage. CONCLUSIONS: For all patty products, mechanical (destructive) and liquid-mediated (nondestructive) adhesion caused damage to neural tissue. The greatest adhesion occurred with Delicot patties. To mitigate patty adhesion and neural tissue damage, surgeons should consider regular irrigation to be essential during neurosurgical procedures.


Assuntos
Lesões Encefálicas/etiologia , Procedimentos Neurocirúrgicos/métodos , Tampões de Gaze Cirúrgicos/efeitos adversos , Aderências Teciduais/etiologia , Animais , Lesões Encefálicas/prevenção & controle , Humanos , Doença Iatrogênica/prevenção & controle , Teste de Materiais , Modelos Animais , Procedimentos Neurocirúrgicos/efeitos adversos , Suínos , Têxteis , Aderências Teciduais/prevenção & controle
20.
BMJ Case Rep ; 20142014 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-24859562

RESUMO

We present the first reported case of ventriculoperitoneal shunt infection secondary to Actinomyces neuii in a paediatric patient. Our patient was managed with temporary shunt removal, intrathecal antibiotics and a prolonged course of intravenous and then oral antibiotics. She went on to make a complete recovery. Subsequent cerebrospinal fluid analysis at 5 months post-treatment demonstrated no evidence of residual infection.


Assuntos
Actinomyces/isolamento & purificação , Actinomicose/terapia , Antibacterianos/uso terapêutico , Remoção de Dispositivo , Penicilinas/uso terapêutico , Infecções Relacionadas à Prótese/terapia , Derivação Ventriculoperitoneal , Actinomicose/microbiologia , Drenagem , Feminino , Humanos , Lactente , Injeções Espinhais , Infecções Relacionadas à Prótese/microbiologia
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