Effect of neurosurgical residency programs on neurosurgical patient outcomes in a single health care system: a cohort study.

BACKGROUND: The evidence on the benefits and drawbacks of involving neurosurgical residents in the care of patients who undergo neurosurgical procedures is heterogeneous. We assessed the effect of neurosurgical residency programs on the outcomes of such patients in a large single-payer public health care system. METHODS: Ten population-based cohorts of adult patients in Ontario who received neurosurgical care from 2013 to 2017 were identified on the basis of procedural codes, and the cohorts were followed in administrative health data sources. Patient outcomes by the status of the treating hospital (with or without a neurosurgical residency program) within each cohort were compared with models adjusted for a priori confounders and with adjusted multilevel models (MLMs) to also account for hospital-level factors. RESULTS: A total of 46 608 neurosurgical procedures were included. Operative time was 8%-30% longer in hospitals with neurosurgical residency programs in 9 out of 10 cohorts. Thirty-day mortality was lower in hospitals with neurosurgical residency programs for aneurysm repair (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.20-0.44), cerebrospinal fluid shunting (OR 0.52, 95% CI 0.34-0.79), intracerebral hemorrhage evacuation (OR 0.66, 95% CI 0.52-0.84), and posterior lumbar decompression (OR 0.32, 95% CI 0.15-0.65) in adjusted models. The mortality rates remained significantly different only for aneurysm repair (OR 0.19, 95% CI 0.05-0.69) and cerebrospinal shunting (OR 0.42, 95% CI 0.21-0.85) in MLMs. Length of stay was mostly shorter in hospitals with neurosurgical residents, but this finding did not persist in MLMs. Thirty-day reoperation rates did not differ between hospital types in MLMs. For 30-day readmission rates, only extracerebral hematoma decompression was significant in MLMs (OR 1.41, 95% CI 1.07-1.87). CONCLUSION: Hospitals with neurosurgical residents had longer operative times with similar to better outcomes. Most, but not all, of the differences between hospitals with and without residency programs were explained by hospital-level variables rather than direct effects of residents.

Role of Rostral Superior Colliculus in Gaze Stabilization during Visual Fixation.

Visual fixation (i.e., holding gaze on a specific visual object or location of interest) has been shown to be influenced by activity in the rostral pole of the intermediate layers of the superior colliculus (SCi)-a sensory-motor integration nucleus in the midbrain involved in visual fixation and saccadic eye movement generation. Neurons in the rostral SCi discharge tonically during visual fixation and pause during saccades to locations beyond their foveal visual-sensory or saccadic-motor response fields. Injection of muscimol to deactivate rostral SCi neurons also leads to an increase in fixation instability. However, the precise role of rostral SCi activity for controlling visual fixation has not been established and is actively debated. Here, we address whether this activity reflects signals related to task demands (i.e., maintaining visual fixation) or foveal visual stimulus properties. Two non-human primates performed an oculomotor task that required fixation of a central fixation point (FP) of varying luminance at the start of each trial. During this fixation period, we measured fixational saccades (≤ 2° of the FP, including microsaccades) and fixation-error saccades (> 2° from the FP) in combination with activity from the rostral SCi. Fixation of the lowest FP luminance increased the latency (onset time relative to initial FP foveation) for both fixational and fixation-error saccades. Fifty percent of the rostral SCi neurons exhibited activity that opposed the change in FP luminance and correlated with delayed fixational saccades and increased fixation-error saccades. Twenty-two percent of rostral SCi neurons exhibited activity that followed the change in FP luminance and correlated with earlier fixational saccades and decreased fixation-error saccades. This suggests the rostral SCi contains both sensory-driven and task-related motor signals related to foveal sensory stimuli and visual fixation. This evidence supports a role for the rostral SCi in gaze stabilization and can help inform artificial computational models of vision.

Systemic D1-R and D2-R antagonists in non-human primates differentially impact learning and memory while impairing motivation and motor performance.

Dopamine (DA) modulates cognition in part via differential activation of D1 and D2 receptors within the striatum and prefrontal cortex, yet evidence for cognitive impairments stemming from DA blockade or deficiency is inconsistent. Given the predominance of D1 over D2 receptors (R) in the prefrontal cortex of primates, D1-R blockade should more strongly influence frontal executive function (including working memory), while D2-R blockade should impair processes more strongly associated with the dorsal striatum (including cognitive flexibility, and learning). To test how systemic DA blockade disrupts cognition, we administered D1-R and D2-R like antagonists to healthy monkeys while they performed a series of cognitive tasks. Two selective DA receptor antagonist drugs (SCH-23390 hydrochloride: D1/D5-R antagonist; or Eticlopride hydrochloride: D2/D3-R antagonist) or placebo (0.9% saline) were systemically administered. Four tasks were used: (1) 'visually guided reaching', to test response time and accuracy, (2) 'reversal learning', to test association learning and attention, (3) 'self-ordered sequential search' to test spatial working memory, and (4) 'delayed match to sample' to test object working memory. Increased reach response times and decreased motivation to work for liquid reward was observed with both the D1/D5-R and D2/D3-R antagonists at the maximum dosages that still enabled task performance. The D2/D3-R antagonist impaired performance in the reversal learning task, while object and spatial working memory performance was not consistently affected in the tested tasks for either drug. These results are consistent with the theory that systemic D2/D3-R antagonists preferentially influence striatum processes (cognitive flexibility) while systemic D1/D5-R administration is less detrimental to frontal executive function.

Distinct sensory- and goal-related signals underlie the gap effect in the superior colliculus.

The removal of a fixation point (FP) prior to the appearance of a saccade target (gap effect) influences pre-motor circuits and reduces saccadic reaction time (SRT). Saccade preparation signals underlying the gap effect have been observed within the intermediate layers of the superior colliculus (SCi). Neurons in the caudal SCi, coding a target location, increase their activity during the gap, while neurons in the rostral SCi, with tonic activity related to visual fixation, decrease activity. However, the gap effect confounds two factors: (1) a goal-driven temporal warning component (upcoming saccade target appearance) and (2) a stimulus-driven sensory component (FP disappearance). These factors combine to reduce SRT and elicit pre-target responses in the SCi. To dissociate warning and sensory effects, we altered the luminance of the FP during the gap period (renamed warning period) such that it could increase, decrease, or stay the same. Faster SRTs resulted with larger decrements in FP luminance. Different categories of SCi warning period activity were evaluated: (1) always increasing or decreasing or (2) sensory-linked responses to changes in FP luminance. In the caudal SCi (at the location coding the target), all activity correlated negatively with SRT (i.e., saccade facilitation), and two categories of activity were observed (always increasing or opposing FP luminance changes). In the rostral SCi, four categories of activity were observed: activity that increased or followed the change in FP luminance correlated positively with SRT (i.e., saccade inhibition), while activity that decreased or opposed FP luminance changes correlated negatively with SRT. Such SCi activity reflected both goal-driven saccade preparation signals and FP sensory properties.

Muting, not fragmentation, of functional brain networks under general anesthesia.

Changes in resting-state functional connectivity (rs-FC) under general anesthesia have been widely studied with the goal of identifying neural signatures of consciousness. This work has commonly revealed an apparent fragmentation of whole-brain network structure during unconsciousness, which has been interpreted as reflecting a break-down in connectivity and a disruption of the brain's ability to integrate information. Here we show, by studying rs-FC under varying depths of isoflurane-induced anesthesia in nonhuman primates, that this apparent fragmentation, rather than reflecting an actual change in network structure, can be simply explained as the result of a global reduction in FC. Specifically, by comparing the actual FC data to surrogate data sets that we derived to test competing hypotheses of how FC changes as a function of dose, we found that increases in whole-brain modularity and the number of network communities - considered hallmarks of fragmentation - are artifacts of constructing FC networks by thresholding based on correlation magnitude. Taken together, our findings suggest that deepening levels of unconsciousness are instead associated with the increasingly muted expression of functional networks, an observation that constrains current interpretations as to how anesthesia-induced FC changes map onto existing neurobiological theories of consciousness.

Superior colliculus encodes visual saliency before the primary visual cortex.

Models of visual attention postulate the existence of a bottom-up saliency map that is formed early in the visual processing stream. Although studies have reported evidence of a saliency map in various cortical brain areas, determining the contribution of phylogenetically older pathways is crucial to understanding its origin. Here, we compared saliency coding from neurons in two early gateways into the visual system: the primary visual cortex (V1) and the evolutionarily older superior colliculus (SC). We found that, while the response latency to visual stimulus onset was earlier for V1 neurons than superior colliculus superficial visual-layer neurons (SCs), the saliency representation emerged earlier in SCs than in V1. Because the dominant input to the SCs arises from V1, these relative timings are consistent with the hypothesis that SCs neurons pool the inputs from multiple V1 neurons to form a feature-agnostic saliency map, which may then be relayed to other brain areas.

Differential effects of D1 and D2 dopamine agonists on memory, motivation, learning and response time in non-human primates.

Dopamine (DA) plays a critical role in cognition, motivation and information processing. DA action has been shown to both improve and/or impair cognition across different receptor types, species, subjects and tasks. This complex relationship has been described as an inverted U-shaped function and may be due to the differential effects of DA receptor activation in the striatum and prefrontal cortex. We have investigated the effects of selective DA agonists on cognitive performance in healthy monkeys using a touch screen running tasks from the CAmbridge Neuropsychological Test Automated Battery (CANTAB). One of two DA agonist drugs or placebo was administered prior to each daily CANTAB session: Dihydrexidine hydrochloride (selective D1 agonist, 0.4-0.9 mg/kg), or sumanirole maleate (selective D2 agonist 0.05-0.3 mg/kg). Three CANTAB tasks were tested: (a) "self-ordered sequential search task" which tested spatial working memory, (b) "reversal learning task," which tested association learning, cognitive flexibility and attention and (c) "visually guided reaching task," which tested reaction time and accuracy. At high dosages, the D2 agonist improved spatial working memory performance, while impairing reversal learning and slowing reach response latency. No consistent cognitive effects were observed with the D1 agonist across the dosages tested. A significant decrease in trial completion rate was observed at the higher dosages of both the D1 and D2 agonists which were consistent with decreased motivation. These results are consistent with task-specific effects of a D2 agonist as well as dose specific insensitivities of a D1 agonist on cognitive and motor behaviors in a healthy monkey.

Microstimulation-induced inhibition of thalamic reticular nucleus in non-human primates.

The thalamic reticular nucleus (TRN) modulates activity in the thalamus and controls excitatory input from corticothalamic and thalamocortical glutamatergic projections. It is made up of GABAergic neurons which project topographically to the thalamus. The TRN also receives inhibitory projections from the globus pallidus and the substantia nigra pars reticulata. Photostimulation of the TRN results in local inhibition in rat slice preparations but the effects of local stimulation in vivo are not known. This study aimed to characterize stimulation-evoked responses in the TRN of non-human primates (NHPs). Microelectrodes were inserted into the TRN and neurons were stimulated at 5, 10, 15, and 20 µA using 0.5 s trains at 100 Hz and the subsequent response was recorded from the same electrode. Stimulation in surrounding nuclei and the internal capsule was used for mapping the anatomical borders of the TRN. Stimulation as low as 10 µA resulted in predominantly inhibition, recorded in both single units and background unit activity (BUA). The duration of inhibition (~ 1-3 s) increased with increasing stimulation amplitude and was significantly increased in BUA when single units were present. At 20 µA of current, 93% of the single units (41/44) and 92% of BUA sites (67/73) were inhibited. Therefore, microstimulation of the NHP TRN with low currents results in current-dependent inhibition of single units and BUA. This finding may be useful to further aid in localization of deep thalamic and subthalamic nuclei during brain surgery.

Pharmacological interventions for the prevention of acute postoperative pain in adults following brain surgery.

BACKGROUND: Pain following brain surgery can compromise recovery. Several pharmacological interventions have been used to prevent pain after craniotomy; however, there is currently a lack of evidence regarding which interventions are most effective. OBJECTIVES: The objectives are to assess the effectiveness of pharmacological interventions for prevention of acute postoperative pain in adults undergoing brain surgery; compare them in terms of additional analgesic requirements, incidence of chronic headache, sedative effects, length of hospital stay and adverse events; and determine whether these characteristics are different for certain subgroups. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science and two trial registries together with reference checking and citation searching on 28th of November 2018. SELECTION CRITERIA: We included blinded and non-blinded, randomized controlled trials evaluating pharmacological interventions for the prevention of acute postoperative pain in adults undergoing neurosurgery, which had at least one validated pain score outcome measure. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. We calculated mean differences for the primary outcome of pain intensity; any pain scores reported on a 0 to 100 scale were converted to a 0 to 10 scale. MAIN RESULTS: We included 42 completed studies (3548 participants) and identified one ongoing study. Nonsteroidal anti-inflammatories (NSAIDs) Nonsteroidal anti-inflammatories (NSAIDs) reduce pain up to 24 hours (0 to 6 hours, MD -1.16, 95% CI -1.57 to -0.76; 12 hours, MD -0.62, 95% CI -1.11 to -0.14; 24 hours, MD -0.66, 95% CI -1.18 to -0.13; 6 studies, 742 participants; all high-quality evidence). Results for other outcomes were imprecise (additional analgesic requirements: MD 1.29 mg, 95% CI -5.0 to 2.46, 4 studies, 265 participants; nausea and vomiting RR 1.34, 95% CI 0.30 to 5.94, 2 studies, 345 participants; both low-quality evidence). Dexmedetomidine reduces pain up to 12 hours (0 to 6 hours, MD -0.89, 95% CI -1.27 to -0.51, moderate-quality evidence; 12 hours, MD -0.81, 95% CI -1.21 to -0.42, low-quality evidence). It did not show efficacy at 24 hours (MD -0.08, 95% CI -0.32 to 0.16; 2 studies, 128 participants; low-quality evidence). Dexmedetomidine may decrease additional analgesic requirements (MD -21.36 mg, 95% CI -34.63 to -8.1 mg, 2 studies, 128 participants, low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting RR -0.43, 95% CI 0.06 to 3.08, 3 studies, 261 participants; hypotension RR 0.5, 95% CI 0.05 to 5.28, 3 studies, 184 participants; both low-quality evidence). Scalp blocks may reduce pain up to 48 hours (0 to 6 hours, MD -0.98, 95% CI -1.66 to -0.3, 10 studies, 414 participants; 12 hours, MD -0.95, 95% CI -1.53 to -0.37, 8 studies, 294 participants; 24 hours, MD -0.78, 95% CI -1.52 to -0.05, 9 studies, 433 participants, all low-quality evidence; 48 hours, MD -1.34, 95% CI -2.57 to -0.11, 4 studies, 135 participants, very low-quality evidence. When studies with high risk of bias were excluded, significance remained at 12 hours only. Scalp blocks may decrease additional analgesia requirements (SMD -1.11, 95% CI -1.97 to -0.25, 7 studies, 314 participants). Results for other outcomes were imprecise (nausea and vomiting RR 0.66, 95% CI 0.33 to 1.32, 4 studies, 165 participants, very low-quality evidence). Scalp Infiltration may reduce pain postoperatively but efficacy was inconsistent, with a significant effect at 12 and 48 hours only (12 hours, MD -0.71, 95% CI -1.34 to -0.08, 7 studies, 309 participants, low-quality evidence; 48 hours, MD - 1.09, 95% CI -2.13 to - 0.06, 3 studies, 128 participants, moderate-quality evidence). No benefit was observed at other times (0 to 6 hours, MD -0.64, 95% CI -1.28 to -0.00, 9 studies, 475 participants, moderate-quality evidence; 24 hours, MD -0.39, 95% CI -1.06 to 0.27,6 studies, 260 participants, low-quality evidence. Scalp infiltration may reduce additional analgesia requirements MD -9.56 mg, 95% CI -15.64 to -3.49, 6 studies, 345 participants, very low-quality evidence). When studies with high risk of bias were excluded, scalp infiltration lost the pain benefit at 12 hours and effects on additional analgesia requirements, but retained the pain-reducing benefit at 48 hours (MD -0.56, 95% CI -1.20 to -0.32, 2 studies, 100 participants, very low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting, RR 0.74, 95% CI 0.48 to 1.41, 4 studies, 318 participants, low-quality evidence). Pregabalin or gabapentin may reduce pain up to 6 hours (2 studies, 202 participants), MD -1.15,95% CI -1.66 to -0.6, 2 studies, 202 participants, low-quality evidence). One study examined analgesic efficacy at 12 hours showing significant benefit. No analgesia efficacy was shown at later times (24 hours, MD -0.29, 95% CI -0.78 to -0.19; 48 hours, MD - 0.06, 95% CI -0.86 to 0.77, 2 studies, 202 participants, low-quality evidence). Additional analgesia requirements were not significantly less (MD -0.37 (95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Risk of nausea and vomiting was significantly reduced (RR 0.51, 95% CI 0.29 to 0.89, 3 studies, 273 participants, low-quality evidence). Results for other outcomes were imprecise (additional analgesia requirements: MD -0.37, 95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Acetaminophen did not show analgesic benefit (0 to 6 hours, MD -0.35, 95% CI -1.00 to 0.30; 12 hours, MD -0.51, 95% CI -1.04 to 0.03, 3 studies, 332 participants, moderate-quality evidence; 24 hours, MD -0.34, 95% CI -1.20 to 0.52, 4 studies, 439 participants, high-quality evidence). Results for other outcomes remained imprecise (additional analgesia requirements, MD 0.07, 95% CI -0.86 to 0.99, 4 studies, 459 participants, high-quality evidence; length of hospitalizations, MD -3.71, 95% CI -14.12 to 6.7, 2 studies, 335 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS: There is high-quality evidence that NSAIDs reduce pain up to 24 hours postoperatively. The evidence for reductions in pain with dexmedetomidine, pregabalin or gabapentin, scalp blocks, and scalp infiltration is less certain and of very low to moderate quality. There is low-quality evidence that scalp blocks and dexmedetomidine may reduce additional analgesics requirements. There is low-quality evidence that gabapentin or pregabalin may decrease nausea and vomiting, with the caveat that the total number of events for this comparison was low.

Integrated robotics platform with haptic control differentiates subjects with Parkinson's disease from controls and quantifies the motor effects of levodopa.

BACKGROUND: The use of integrated robotic technology to quantify the spectrum of motor symptoms of Parkinson's Disease (PD) has the potential to facilitate objective assessment that is independent of clinical ratings. The purpose of this study is to use the KINARM exoskeleton robot to (1) differentiate subjects with PD from controls and (2) quantify the motor effects of dopamine replacement therapies (DRTs). METHODS: Twenty-six subjects (Hoehn and Yahr mean 2.2; disease duration 0.5 to 15 years) were evaluated OFF (after > 12 h of their last dose) and ON their DRTs with the Unified Parkinson's Disease Rating Scale (UPDRS) and the KINARM exoskeleton robot. Bilateral upper extremity bradykinesia, rigidity, and postural stability were quantified using a repetitive movement task to hit moving targets, a passive stretch task, and a torque unloading task, respectively. Performance was compared against healthy age-matched controls. RESULTS: Mean hand speed was 41% slower and 25% fewer targets were hit in subjects with PD OFF medication than in controls. Receiver operating characteristic (ROC) area for hand speed was 0.94. The torque required to stop elbow movement during the passive stretch task was 34% lower in PD subjects versus controls and resulted in an ROC area of 0.91. The torque unloading task showed a maximum displacement that was 29% shorter than controls and had an ROC area of 0.71. Laterality indices for speed and end total torque were correlated to the most affected side. Hand speed laterality index had an ROC area of 0.80 against healthy controls. DRT administration resulted in a significant reduction in a cumulative score of parameter Z-scores (a measure of global performance compared to healthy controls) in subjects with clinically effective levodopa doses. The cumulative score was also correlated to UPDRS scores for the effect of DRT. CONCLUSIONS: Robotic assessment is able to objectively quantify parkinsonian symptoms of bradykinesia, rigidity and postural stability similar to the UPDRS. This integrated testing platform has the potential to aid clinicians in the management of PD and help assess the effects of novel therapies.

Linking express saccade occurance to stimulus properties and sensorimotor integration in the superior colliculus.

Express saccades represent the fastest possible eye movements to visual targets with reaction times that approach minimum sensory-motor conduction delays. Previous work in monkeys has identified two specific neural signals in the superior colliculus (SC: a midbrain sensorimotor integration structure involved in gaze control) that are required to execute express saccades: 1) previsual activity consisting of a low-frequency increase in action potentials in sensory-motor neurons immediately before the arrival of a visual response; and 2) a transient visual-sensory response consisting of a high-frequency burst of action potentials in visually responsive neurons resulting from the appearance of a visual target stimulus. To better understand how these two neural signals interact to produce express saccades, we manipulated the arrival time and magnitude of visual responses in the SC by altering target luminance and we examined the corresponding influences on SC activity and express saccade generation. We recorded from saccade neurons with visual-, motor-, and previsual-related activity in the SC of monkeys performing the gap saccade task while target luminance was systematically varied between 0.001 and 42.5 cd/m(2) against a black background (∼0.0001 cd/m(2)). Our results demonstrated that 1) express saccade latencies were linked directly to the arrival time in the SC of visual responses produced by abruptly appearing visual stimuli; 2) express saccades were generated toward both dim and bright targets whenever sufficient previsual activity was present; and 3) target luminance altered the likelihood of producing an express saccade. When an express saccade was generated, visuomotor neurons increased their activity immediately before the arrival of the visual response in the SC and saccade initiation. Furthermore, the visual and motor responses of visuomotor neurons merged into a single burst of action potentials, while the visual response of visual-only neurons was unaffected. A linear combination model was used to test which SC signals best predicted the likelihood of producing an express saccade. In addition to visual response magnitude and previsual activity of saccade neurons, the model identified presaccadic activity (activity occurring during the 30-ms epoch immediately before saccade initiation) as a third important signal for predicting express saccades. We conclude that express saccades can be predicted by visual, previsual, and presaccadic signals recorded from visuomotor neurons in the intermediate layers of the SC.

Spatio-temporal response properties of local field potentials in the primate superior colliculus.

Local field potentials (LFPs) are becoming increasingly popular in neurophysiological studies. However, to date, most of the knowledge about LFPs has been obtained from cortical recordings. Here, we recorded single unit activity (SUA) and LFPs simultaneously from the superior colliculus (SC) of behaving rhesus monkeys. The SC is a midbrain structure that plays a central role in the visual orienting response. Previous studies have characterised the visual and visuomotor response properties of SUA in the superficial layers of the SC and the intermediate layers of the SC, respectively. We found that the signal properties of SUA were well preserved in the LFPs recorded from the SC. The SUA and LFPs had similar spatial and temporal properties, and the response properties of LFPs differed across layers, i.e. purely visual in the superficial layers of the SC but showing significant motor responses in the intermediate layers of the SC. There were also differences between SUA and LFPs. LFPs showed a significant reversal of activity following the phasic visual response, suggesting that the neighboring neurons were suppressed. The results indicate that the LFP can be used as a reliable measure of the SC activity in lieu of SUA, and open up a new way to assess sensorimotor processing within the SC.

Cooling for cerebral protection during brain surgery.

BACKGROUND: Patients undergoing neurosurgery are at risk of cerebral ischaemia with resultant cerebral hypoxia and neuronal cell death. This can increase both the risk of mortality and long term neurological disability. Induced hypothermia has been shown to reduce the risk of cerebral ischaemic damage in both animal studies and in humans who have been resuscitated following cardiac arrest. This had lead to an increasing interest in its neuroprotective potential in neurosurgical patients. This review was originally published in 2011 and did not find any evidence of either effectiveness or harm in these patients. This updated review was designed to capture current evidence to readdress these issues. OBJECTIVES: To evaluate the effectiveness and safety profile of induced hypothermia versus normothermia for neuroprotection in patients undergoing brain surgery. Effectiveness was to be measured in terms of short and long term mortality and functional neurological outcomes. Safety was to be assessed in terms of the rate of the adverse events infection, myocardial infarction, ischaemic stroke, congestive cardiac failure and any other adverse events reported by the authors of the included studies. SEARCH METHODS: For the original review, the authors searched the databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), EMBASE (OvidSP) and LILACS to November 2010. For the updated review all these databases were re-searched from November 2010 to May 2014.For both the original and updated versions, grey literature was sought by searching reference lists of identified studies and relevant review articles, and conference proceedings. No language restrictions were applied. SELECTION CRITERIA: As in the original review, we included randomized controlled trials (RCTs) of induced hypothermia versus normothermia for neuroprotection in patients of any age and gender undergoing brain surgery, which addressed mortality, neurological morbidity or adverse event outcomes. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data and two independently assessed the risk of bias of the included studies. Any discrepancies were resolved by discussion between authors. MAIN RESULTS: In this updated review, one new ongoing study was found but no new eligible completed studies were identified. This update was therefore conducted using the same four studies included in the original review. These studies included a total of 1219 participants, mean age 40 to 54 years. All included studies were reported as RCTs. Two were multicentred, together including a total of 1114 patients who underwent cerebral aneurysm clipping, and were judged to have an overall low risk of bias. The other two studies were single centred. One included 80 patients who had a craniotomy following severe traumatic brain injury and was judged to have an unclear or low risk of bias. The other study included 25 patients who underwent hemicranicectomy to relieve oedema following cerebral infarction and was judged to have an unclear or high risk of bias. All studies assessed hypothermia versus normothermia. Overall 608 participants received hypothermia with target temperatures ranging from 32.5 °C to 35 °C, and 611 were assigned to normothermia with the actual temperatures recorded in this group ranging form 36.5 °C to 38 °C. For those who were cooled, 556 had cooling commenced immediately after induction of anaesthesia that was continued until the surgical objective of aneurysm clipping was achieved, and 52 had cooling commenced immediately after surgery and continued for 48 to 96 hours.Pooled estimates of effect were calculated for the outcomes mortality during treatment or follow-up (ranging from in-hospital to one year); neurological outcome measured in terms of the Glasgow Outcome Score (GOS) of 3 or less; and adverse events of infections, myocardial infarction, ischaemic stroke and congestive cardiac failure. With regards to mortality, the risk of dying if allocated to hypothermia compared to normothermia was not statistically significantly different (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.59 to 1.27, P = 0.47). There was no indication that the time at which cooling was started affected the risk of dying (RR with intraoperative cooling 0.95, 95% CI 0.60 to 1.51, P = 0.83; RR for cooling postoperatively 0.67, 95% CI 0.34 to 1.35, P = 0.26). For the neurological outcome, the risk of having a poor outcome with a GOS of 3 or less was not statistically different in those who received hypothermia versus normothermia (RR 0.80, 95% CI 0.61 to 1.04, P = 0.09). Again there was no indication that the time at which cooling was started affected this result. Regarding adverse events, there was no statistically significant difference in the incidence in those allocated to hypothermia versus normothermia for risk of surgical infection (RR 1.20, 95% CI 0.73 to 1.97, P = 0.48), myocardial infarction (RR 1.86, 95% CI 0.69 to 4.98, P = 0.22), ischaemic stroke (RR 0.93, 95% CI 0.82 to 1.05, P = 0.24) or congestive heart failure (RR 0.85, 95% CI 0.60 to 1.21, P = 0.38). In contrast to other outcomes, where time of application of cooling did not change the statistical significance of the effect estimates, there was a weak statistically significant increased risk of infection in those who were cooled postoperatively versus those who were not cooled (RR 1.77, 95% CI 1.05 to 2.98, P = 0.03). Overall, as in the original review, no evidence was found that the use of induced hypothermia was either beneficial or harmful in patients undergoing neurosurgery. AUTHORS' CONCLUSIONS: We found no evidence that the use of induced hypothermia was associated with a significant reduction in mortality or severe neurological disability, or an increase in harm in patients undergoing neurosurgery.

Giant sequoia (Sequoiadendron giganteum) in the UK: carbon storage potential and growth rates.

Giant sequoias (Sequoiadendron giganteum) are some of the UK's largest trees, despite only being introduced in the mid-nineteenth century. There are an estimated half a million giant sequoias and closely related coastal redwoods (Sequoia sempervirens) in the UK. Given the recent interest in planting more trees, partly due to their carbon sequestration potential and also their undoubted public appeal, an understanding of their growth capability is important. However, little is known about their growth and carbon uptake under UK conditions. Here, we focus on S. giganteum and use three-dimensional terrestrial laser scanning to perform detailed structural measurements of 97 individuals at three sites covering a range of different conditions, to estimate aboveground biomass (AGB) and annual biomass accumulation rates. We show that UK-grown S. giganteum can sequester carbon at a rate of 85 kg yr-1, varying with climate, management and age. We develop new UK-specific allometric models for S. giganteum that fit the observed AGB with r 2 > 0.93 and bias < 2% and can be used to estimate S. giganteum biomass more generally. This study provides the first estimate of the growth and carbon sequestration of UK open-grown S. giganteum and provides a baseline for estimating their longer-term carbon sequestration capacity.

Endothelial ICAM-1 protein induction is regulated by cytosolic phospholipase A2α via both NF-κB and CREB transcription factors.

The regulated expression of ICAM-1 plays an important role in inflammatory processes and immune responses. The present study aimed to determine the in vivo involvement of cytosolic phospholipase A(2)α (cPLA(2)α) in ICAM-1 overexpression during inflammation and to elucidate the cPLA(2)α-specific role in signal events leading to ICAM-1 upregulation in endothelial cells. cPLA(2)α and ICAM-1 upregulation were detected in inflamed paws of mice with collagen-induced arthritis and in periepididymal adipose tissue of mice fed a high-fat diet. Intravenous injection of 2 mg/kg oligonucleotide antisense against cPLA(2)α (AS) that reduced cPLA(2)α upregulation also decreased ICAM-1 overexpression, suggesting a key role of cPLA(2)α in ICAM-1 upregulation during inflammation. Preincubation of endothelial ECV-304 cells that express ICAM-1 and of HUVEC that express ICAM-1 and VCAM-1 with 1 µM AS prevented cPLA(2)α and the adhesion molecule upregulation induced by TNF-α and inhibited their adherence to phagocyte like-PLB cells. Whereas AS did not inhibit NADPH oxidase 4-NADPH oxidase activity, inhibition of oxidase activity attenuated cPLA(2)α activation, suggesting that NADPH oxidase acts upstream to cPLA(2)α. Attenuating cPLA(2)α activation by AS or diphenylene iodonium prevented the induction of cyclooxygenase-2 and the production of PGE(2) that were essential for ICAM-1 upregulation. Inhibition of cPLA(2)α activity by AS inhibited the phosphorylation of both p65 NF-κB on Ser(536) and protein kinase A-dependent CREB. To our knowledge, our results are the first to show that CREB activation is involved in ICAM-1 upregulation and suggest that cPLA(2)α activated by NADPH oxidase is required for sequential phosphorylation of NF-κB by an undefined kinase and CREB activation by PGE(2)-mediated protein kinase A.

Linking visual response properties in the superior colliculus to saccade behavior.

Here we examined the influence of the visual response in the superior colliculus (SC) (an oculomotor control structure integrating sensory, motor and cognitive signals) on the development of the motor command that drives saccadic eye movements in monkeys. We varied stimulus luminance to alter the timing and magnitude of visual responses in the SC and examined how these changes correlated with resulting saccade behavior. Increasing target luminance resulted in multiple modulations of the visual response, including increased magnitude and decreased response onset latency. These signal modulations correlated strongly with changes in saccade latency and metrics, indicating that these signal properties carry through to the neural computations that determine when, where and how fast the eyes will move. Thus, components of the earliest part of the visual response in the SC provide important building blocks for the neural basis of the sensory-motor transformation, highlighting a critical link between the properties of the visual response and saccade behavior.

Dynamics of seizure termination in a non-human primate kindling model of mesial temporal lobe epilepsy.

Epilepsy is characterized by recurrent, unprovoked seizures which involve transient neuronal hyperexcitability or hypersynchrony. Focal seizures with impaired awareness (FIAS) are commonly related to mesial temporal lobe epilepsy (mTLE) with hippocampal sclerosis and potentially status epilepticus. How seizures terminate spontaneously remains an unanswered question fundamental to epileptology. To study seizure termination, we induced FIAS in a nonhuman primate (NHP) model with electrical kindling. Kindling stimulation was delivered to the basolateral amygdala once weekly for 30 weeks. Chronic linear microelectrode arrays were implanted in NHP mesial temporal lobe targets: the hippocampus, amygdala and entorhinal cortex. Daily electrophysiologic recordings were obtained from all targets before, during and after stimulation to monitor changes to local field potential activity. We detect prominent changes in electrophysiologic dynamics before after-discharge (AD; subclinical, electrographic seizures which begin after a stimulus) self-termination. Specifically, at seizure termination the power of the extra-focal theta rhythm increased, and the theta phase was shown to couple with the gamma rhythm within the seizure focus. The electrical current threshold for eliciting an after-discharge decreased from >700µA to 15µA. The refractory period, which prevents the induction of seizure events at threshold, was initially 3 minutes in duration. At 30 weeks after FIAS induction the refractory period increased to over 5 minutes in duration. Understanding the electrophysiologic dynamics that reflect endogenous seizure termination mechanisms may be a valuable consideration for refining intervention strategies for treatment of epilepsy. Clinical Relevance- Our findings provide further electrophysiologic description of the endogenous mechanisms behind seizure termination in a healthy brain. This work specifically highlights the importance of considering targets outside the epileptogenic zone for therapeutic intervention.

Reverse Visually Guided Reaching in Patients with Parkinson's Disease.

In addition to motor symptoms such as difficulty in movement initiation and bradykinesia, patients with Parkinson's disease (PD) display nonmotor executive cognitive dysfunction with deficits in inhibitory control. Preoperative psychological assessments are used to screen for impulsivity that may be worsened by deep brain stimulation (DBS) of the subthalamic nucleus (STN). However, it is unclear whether anti-Parkinson's therapy, such as dopamine replacement therapy (DRT) or DBS, which has beneficial effects on motor function, adversely affects inhibitory control or its domains. The detrimental effects of STN-DBS are more apparent when tasks test the inhibition of habitual prepotent responses or involve complex cognitive loads. Our goal was to use a reverse visually guided reaching (RVGR) task, a hand-based version of the antisaccade task, to simultaneously measure motor performance and response inhibition in subjects with PD. We recruited 55 healthy control subjects, 26 PD subjects receiving treatment with DRTs, and 7 PD subjects receiving treatment with STN-DBS and DRTs. In the RVGR task, a cursor moved opposite to the subject's hand movement. This was compared to visually guided reaching (VGR) where the cursor moved in the same direction as the subject's hand movement. Reaction time, mean speed, and direction errors (in RVGR) were assessed. Reaction times were longer, and mean speeds were slower during RVGR compared to VGR in all three groups but worse in untreated subjects with PD. Treatment with DRTs, DBS, or DBS + DRT improved the reaction time and speed on the RVGR task to a greater extent than VGR. Additionally, DBS or DBS + DRT demonstrated an increase in direction errors, which was correlated with decreased reaction time. These results show that the RVGR task quantifies the benefit of STN-DBS on bradykinesia and the concomitant reduction of proactive inhibitory control. The RVGR task has the potential to be used to rapidly screen for preoperative deficits in inhibitory control and to titrate STN-DBS, to maximize the therapeutic benefits on movement, and minimize impaired inhibitory control.

Anesthesia can be safely provided for children in a high-field intraoperative magnetic resonance imaging environment.

OBJECTIVES: To describe the challenges associated with providing safe anesthesia and perioperative care for children in a remote intraoperative magnetic resonance (iMR) operating room (OR) and to identify perioperative anesthesia outcomes, including adverse events related to the iMR environment. BACKGROUND: Increasingly, children undergo neurosurgical procedures in a high-field iMR OR. We describe a 10-year experience of providing anesthesia for children in this environment with a mobile 1.5-Tesla magnet. METHODS: A 10-year retrospective analysis was conducted of children who underwent neurosurgical procedures in a high-field mobile iMR OR. Primary outcomes related to perioperative adverse events and recovery profiles. Results were expressed as mean ± sd or median (range), as appropriate. RESULTS: One hundred and five procedures were performed on 98 children, aged 4 months-18 years, weighing 6-112 kg. The commonest two diagnostic categories were tumor (n = 52) and seizures (n = 27). Median anesthetic time was 439 (185-710) mins. There were no significant adverse events related to the iMR environment. The mean postanesthetic care unit admission temperature was 37 ± 0.9°C and the mean modified Aldrete Score at 30 mins was 7.2 ± 0.9. Two patients experienced seizures in the immediate postoperative period, readily controlled with propofol. There was one breach of MR safety protocol, and no adverse events related to patient transport. CONCLUSIONS: Anesthesia and perioperative care of children in an iMR setting were associated with a very low incidence of complications, despite the duration of the procedures involved. Such success depends upon a cohesive team-based approach.

The Dostoyevsky effect: epileptogenesis and memory enhancement after kindling stimulation in the primate basolateral amygdala.

Kindling is an electrical stimulation technique used to lower the threshold for epileptogenic activity in the brain. It can also be used as a tool to investigate electrophysiologic alterations that occur as a result of seizures. Epileptiform activity, like seizures and after-discharges (AD; evoked epileptiform activity), commonly cause memory impairment but rarely, can elicit vivid memory retrieval. We kindled the basolateral amygdala of a non-human primate (NHP) once weekly and had him perform a spatial memory task in a 3D virtual environment before, during and after kindling. AD were associated with an initial average performance increase of 46.6%. The enhancement which followed AD persisted up to 2 days. Memory task performance enhancement was accompanied by significant resetting of hippocampal theta oscillations and robust hippocampal potentiation as measured by field evoked potentials. However, neither lasted throughout the duration of performance enhancement. Sharp-wave ripples (SWR), a local field event that supports episodic memory, were generated more often throughout the period of enhancement. SWR rate increased from 14.38 SWR per min before kindling to 24.22 SWR per min after kindling on average. Our results show that kindling can be associated with improved memory. Memory function appears to depend on the particular induction circuit and the resultant excitation/inhibition ratio of the mesial temporal lobe network. Investigating the electrophysiologic underpinnings of this observed memory enhancement is an important step towards understanding the network alterations that occur after seizures and stimulation.Clinical Relevance- Our findings provide new insight into the effects of kindling stimulation in the primate brain. Kindling can cause increase MTL synchrony and the frequency of spontaneous seizures in a primate. This work highlights important considerations for therapeutic deep brain stimulation.