Management of cervical fractures in ankylosing spondylitis patients: immediate fixation effort via vertebroplasty with one-staged combined anterior and posterior fixation.

The ankylosed spine is prone to fracture even as a result of minor trauma due to its changed biomechanical properties. Fractures in ankylosing spondylitis (AS) patients are highly unstable and surgical intervention for fixation is warranted. Implant failure rates are high and combined anterior and posterior fixation is required to enhance the fixation outcome. For fusion, anterior interbody fusion or posterior bone graft fusion is often adopted. Here, we introduce a new method which combines vertebroplasty with anterior and posterior approaches to improve pain control, facilitate the long-term fixation outcome and mechanics, and decrease perioperative risks with prompt stabilization, especially in patients with spine curve deformity. Here, we present two AS cases with cervical spine fracture treated with this new method.

Intraoperative ultrasound is valuable for detecting intracranial hematoma progression and decreasing mortality in traumatic brain injury.

BACKGROUND: Our aim was to explore the clinical benefit of intraoperative ultrasound in decompressive craniectomy (DC) for traumatic brain injury (TBI). METHODS: From January 1, 2018, through April 30, 2021, 54 patients who developed acute subdural hematoma (SDH) due to blunt injury and underwent DC with or without intraoperative ultrasound assistance were retrospectively included in our study. Logistic regression analyses were performed to compare the therapeutic efficacy in the two groups. RESULTS: In the ultrasound group (14 patients, 25.93%), intraoperative ultrasound was used for assisting hematoma removal and/or ventriculostomy during DC. In the control group (40 patients, 74.07%), ultrasound was not used during the operation and ventriculostomy was not performed. No statistically significant differences in age, sex, initial Glasgow Coma Scale (GCS) score, blood loss, postoperative intracranial pressure (ICP), duration of hyperosmolar therapy, or Glasgow Outcome Scale Extended (GOS-E) score 6 months after injury were observed. No mortality was recorded in the ultrasound group. The mortality rate in the control group during hospitalization was 25% (p < 0.05). CONCLUSIONS: Intraoperative ultrasound is helpful for intracranial hematoma removal and ventriculostomy with cerebrospinal fluid drainage and decreases mortality in experienced hands. The reason for higher mortality rate in the control group might result from poor hematoma clearance rate and poor postoperative intracranial pressure control. It is a useful tool for diagnosing and assisting with treatment in cases of TBI.

Non-missile penetrating brain injury-surgical techniques for removing a long penetrating foreign body: a case report.

PURPOSE: Penetrating brain injury (PBI), a relatively uncommon injury, is associated with remarkable secondary complications such as vascular injury, intracranial haemorrhage, infection, and mortality. Non-missile PBI (NMPBI) due to sharp or blunt objects is usually treated surgically by removing the penetrating object, evacuating the associated haemorrhage, identifying possible bleeders along with haemostasis, and performing debridement. Various approaches are used for different scenarios of non-missile PBI according to the object's characteristics, penetrating site, depth, associated intracerebral haemorrhage (ICH), and presence of vascular injury along the penetrating tract. NMPBI cases are rarely reported among civilians. We herein describe a patient who was successfully treated for NMPBI, as well as frontal ICH, by simultaneously removing the heavy, metallic penetrating foreign body. METHODS: We performed corticotomy through a shorter tract instead of a deep penetrating trajectory, which minimizes the extent of damage to the brain and enables immediate management of vascular injury under direct vision while removing the foreign body, and intraoperative sonography, which provides real-time information of the penetrating object and the surrounding brain structure. We did not perform computed tomography angiography and digital subtraction angiography (DSA) because the stab location was at the frontal region, with low risk of vascular injury. Moreover, DSA is time-consuming, which may delay decompressive surgery. RESULTS: The patient was successfully treated through an alternative approach removing the long, heavy, metallic penetrating foreign body and eliminating the accompanying frontal ICH simultaneously. Focal brain abscess developed 8 days after the injury and resolved completely after antibiotics treatment. Dysphasia gradually improved but right distal limbs weakness with spasticity is still present. CONCLUSIONS: Our findings suggest prompt diagnosis by preoperative imaging, screening of vascular injury, decompression with debridement, and antibiotics treatment are important. The alternative surgical approach we proposed is exceptional and should be considered while treating patients with deep NMPBI.

Endovascular Intervention Versus Surgery in Ruptured Intracranial Aneurysms in Equipoise: A Systematic Review.

Background and Purpose- The benefits of endovascular intervention over surgery in the treatment of ruptured aneurysms of anterior circulation remains uncertain. Recently, published studies did not find superiority of endovascular intervention, challenging earlier evidence from a clinical trial. The earlier evidence also had a higher than average proportion of patients in good clinical status, leading to uncertainty about external validity of earlier trials. Methods- We performed a systematic review of studies after 2005 under a protocol published in the International Prospective Register of Systematic Reviews. Primary outcomes were posttreatment rebleeding and adverse events (procedural complications). Secondary outcomes were dependency at 3 to 6 and 12 months, delayed cerebral ischemia, and seizures. Results- Rebleeding was more frequent after endovascular intervention (Peto OR, 2.18 [95% CI, 1.29-3.70]; 3104 participants; 15 studies; I2=0%, Grading of Recommendations, Assessment, Development and Evaluation: very low certainty of evidence). Fewer adverse events were reported with the endovascular intervention (RR, 0.71 [95% CI, 0.53-0.95]; 1661 participants; 11 studies; I2=14%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence). Three to six months dependency (RR, 0.82 [95% CI, 0.73-0.93]; 4081 participants; 18 studies; I2=15%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence) and 12-month dependency (RR, 0.76 [95% CI, 0.66-0.86]; 1981 participants; 10 studies; I2=0%, Grading of Recommendations, Assessment, Development and Evaluation: low certainty of evidence) were lower after endovascular intervention. Conclusions- This study found consistent results between recent studies and the earlier evidence, in that endovascular intervention results in lower chance of dependency compared with surgery for repair of ruptured anterior circulation aneurysms. A lower proportion of patients in good clinical status in this review supports the application of the earlier evidence. Registration- URL: https://www.crd.york.ac.uk/PROSPERO. Unique identifier: CRD42018090396.

Noninvasive assessment of intracranial elastance and pressure in spontaneous intracranial hypotension by MRI.

BACKGROUND: Spontaneous intracranial hypotension (SIH) is often misdiagnosed, and can lead to severe complications. Conventional MR sequences show a limited ability to aid in this diagnosis. MR-based intracranial pressure (MR-ICP) may be able to detect changes of intracranial elastance and pressure. PURPOSE: To determine whether MR-ICP is able to differentiate SIH patients from normal subjects, improve diagnostic sensitivity, and provide an insight into the pathophysiology. STUDY TYPE: Prospective. SUBJECTS: Twenty-eight SIH cases with orthostatic headache and 20 healthy volunteers. FIELD STRENGTH/SEQUENCE: Cine phase-contrast MRI on a 1.5T scanner. ASSESSMENT: Intracranial elastance (IE) was derived from the ratio of the peak-to-peak cerebrospinal fluid (CSF) pressure gradient (PGcsf-pp ) and intracranial volume change, obtained by summing all flows before each sequential cardiac frame. STATISTICAL TESTS: Student's t-test was used to compare the MR-ICP indexes and flow parameters between SIH patients and healthy volunteers (P < 0.01). RESULTS: The SIH patients with cervical epidural venous dilatation (EVD) had an IE of 0.121 ± 0.027 mmHg/cm/ml, significantly higher than that of the normal volunteers (0.085 ± 0.027 mmHg/cm/ml; P = 0.002). In contradistinction, the EVD-negative SIH patients, including four with no sign of CSF leaks, had significantly lower IE (0.055 ± 0.012 mmHg/cm/ml) compared with the normal volunteers and the EVD-positive group (P = 0.001, P < 0.001). The EVD-negative patients had significantly lower PGcsf-pp (0.024 ± 0.007 mmHg/cm) compared with the normal volunteers and the EVD-positive group (0.035 ± 0.011 mmHg/cm, 0.040 ± 0.010 mmHg/cm; P = 0.003, P < 0.001). Additionally, the MRI flow study showed a significant decrease in transcranial inflow and outflow of SIH patients (P < 0.01). DATA CONCLUSION: We found that the MR-ICP method is potentially more sensitive than morphological MRI in the early diagnosis of SIH. Also, contrary to common belief, our results suggest that an abnormal craniospinal elastance might be the cause of SIH, instead of CSF leak. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1255-1263.

Quality of return to work in patients with mild traumatic brain injury: a prospective investigation of associations among post-concussion symptoms, neuropsychological functions, working status and stability.

PRIMARY OBJECTIVE: Although 'return to work' (RTW) has been always emphasized for patients with mild traumatic brain injury (MTBI), methodological drawbacks weakened its representativeness. This study thus aims to evaluate the 'work quality' (WQ) which originated from 'working status' and 'working stability' simultaneously, and to further explore the associations among post-concussion symptoms (PCS), neuropsychological functions and WQ. METHODS AND PROCEDURES: A total of 179 participants, which included 132 patients with MTBI and 47 healthy participants, were prospectively recruited. The work quality index (WQI) was developed to evaluate WQ. All patients were evaluated for their PCS, neuropsychological functions and WQ at two weeks post-injury (T1), while PCS and WQ were recorded by one month post-injury (T2). RESULTS: More than half of the patients were not able to retain their pre-injury jobs at T1, while 26% of the patients still failed to regain previous works at T2. Interestingly, WQ was significantly associated with educational levels and physical PCS, such as headache and dizziness. CONCLUSIONS: Simultaneously considering working status and stability to reveal the quality of RTW is merited. A higher educational level might be a protective factor for successful RTW, and ameliorating physical symptoms is also necessary to get favourable WQ by one month after MTBI.

Climate refugia: joint inference from fossil records, species distribution models and phylogeography.

Climate refugia, locations where taxa survive periods of regionally adverse climate, are thought to be critical for maintaining biodiversity through the glacial-interglacial climate changes of the Quaternary. A critical research need is to better integrate and reconcile the three major lines of evidence used to infer the existence of past refugia - fossil records, species distribution models and phylogeographic surveys - in order to characterize the complex spatiotemporal trajectories of species and populations in and out of refugia. Here we review the complementary strengths, limitations and new advances for these three approaches. We provide case studies to illustrate their combined application, and point the way towards new opportunities for synthesizing these disparate lines of evidence. Case studies with European beech, Qinghai spruce and Douglas-fir illustrate how the combination of these three approaches successfully resolves complex species histories not attainable from any one approach. Promising new statistical techniques can capitalize on the strengths of each method and provide a robust quantitative reconstruction of species history. Studying past refugia can help identify contemporary refugia and clarify their conservation significance, in particular by elucidating the fine-scale processes and the particular geographic locations that buffer species against rapidly changing climate.

Limited hybridization across an edaphic disjunction between the gabbro-endemic shrub Ceanothus roderickii (Rhamnaceae) and the soil-generalist Ceanothus cuneatus.

PREMISE OF THE STUDY: Hybridization is thought to have played an important role in diversification of the speciose shrub genus Ceanothus; putative hybrid species have been described, and data suggest that intrinsic barriers may not exist among closely related species. However, the extent to which hybridization occurs in the wild is not known, and little is understood about how extrinsic factors such as soil chemistry may influence the process. The present research focuses on the gabbro-endemic C. roderickii and the closely related soil-generalist C. cuneatus. Though the species occur peripatrically, they remain distinct across an edaphic disjunction. • METHODS: AFLP was used to quantify hybridization and introgression. Biological data and experiments were used to test for prezygotic isolation. Growth trials were used to test for local adaptation and selection against hybrids. • KEY RESULTS: Ceanothus cuneatus and C. roderickii were strongly differentiated morphologically and genetically, despite a lack of evidence for prezygotic barriers. Hybrids and back-crosses were present but infrequent. Finally, there was selection against hybrids in nonnative soil. • CONCLUSIONS: There is little genetic exchange between the focal species across an edaphic disjunction, despite the absence of prezygotic barriers. This result implies that soil conditions, as well as other extrinsic factors, should be considered as forces that may restrict hybridization and gene flow in Ceanothus, influencing local adaptation and speciation. Findings presented here are significant because they imply that exchange of genetic material between plants may be limited directly by the abiotic environment, rather than by the biology of the plants.

Host density drives the postglacial migration of the tree parasite, Epifagus virginiana.

To survive changes in climate, successful species shift their geographic ranges to remain in suitable habitats. For parasites and other highly specialized species, distributional changes not only are dictated by climate but can also be engineered by their hosts. The extent of host control on parasite range expansion is revealed through comparisons of host and parasite migration and demographic histories. However, understanding the codistributional history of entire forest communities is complicated by challenges in synthesizing datasets from multiple interacting species of differing datatypes. Here we integrate genetic and fossil pollen datasets from a host-parasite pair; specifically, the population structure of the parasitic plant (Epifagus virginiana) was compared with both its host (Fagus grandifolia) genetic patterns and abundance data from the paleopollen record of the last 21,000 y. Through tests of phylogeographic structure and spatial linear regression models we find, surprisingly, host range changes had little effect on the parasite's range expansion and instead host density is the main driver of parasite spread. Unlike other symbionts that have been used as proxies to track their host's movements, this parasite's migration routes are incongruent with the host and instead reflect the greater importance of host density in this community's assembly. Furthermore, these results confirm predictions of disease ecological models regarding the role of host density in the spread of pathogens. Due to host density constraints, highly specialized species may have low migration capacities and long lag times before colonization of new areas.

Divergent manifestations of irritability in patients with mild and moderate-to-severe traumatic brain injury: perspectives of awareness and neurocognitive correlates.

PRIMARY OBJECTIVES: To evaluate irritability in patients with mild traumatic brain injury (mTBI) and moderate-to-severe traumatic brain injury (msTBI), respectively. RESEARCH DESIGN: A prospective study was conducted at a level I trauma centre. METHODS AND PROCEDURES: A total of 160 participants, which included 80 healthy subjects and 80 patients with TBI, were recruited. Irritability was assessed by the National Taiwan University Irritability Scale and other cognitive functions, which included memory, executive function and information processing, were also evaluated. MAIN OUTCOMES AND RESULTS: The results showed post-injury self-reported irritability in patients with mTBI and family-reported irritability in patients with msTBI were significantly higher than irritability reported by healthy participants. Irritability was significantly associated with information processing ability in patients with mTBI, but it was not associated with any cognitive functions in patients with msTBI. CONCLUSIONS: Irritability was found to be prominent after TBI. Divergent causes of irritability seemed apparent in patients with mTBI and msTBI. Irritability after mTBI appeared might be related to the cognitive functions disrupted after the injury, whereas irritability after msTBI appeared to result directly from the brain lesions involved.

Long-term work quality of patients with mild traumatic brain injury: The associations with postconcussion symptoms.

Return to work (RTW) has always been a determinant functional outcome in patients with mild traumatic brain injury (MTBI). However, the quality of long-term RTW was still unclear. This study thus aims to examine long-term work quality and to reveal its associating factors. A total of 110 patients with MTBI was prospectively recruited. Post-concussion symptoms (PCS) and RTW were evaluated by the Checklist of Post-Concussion Symptoms (CPCS) and Work Quality Index (WQI) respectively at one-week and long-term evaluation (M = 2.90 years, SD = 1.29) post-injury. Only 16% of patients can successfully RTW at one-week post-injury, while 69% of patients have retained their jobs at long-term evaluations. Importantly, 12% of patients had to work under the adverse impacts of PCS at one-week after MTBI, and long-term WQI was significantly associated with PCS at one-week post-injury. Almost 1/3 of patients still had unfavorable long-term work quality even though they could return to work. Thus, a careful evaluation of the early PCS endorsement and work quality for patients with MTBI is merited.

Irritability following traumatic brain injury: divergent manifestations of annoyance and verbal aggression.

PRIMARY OBJECTIVES: To evaluate irritability following traumatic brain injury. RESEARCH DESIGN: A prospective study was conducted at a level I trauma centre. METHODS AND PROCEDURES: One hundred and forty-four participants, which included 80 healthy subjects and 64 patients suffering from TBI, were recruited. Irritability was assessed by the National Taiwan University Irritability Scale (NTUIS) from patients themselves and their families. MAIN OUTCOMES AND RESULTS: the results showed 14.8% of patients and 29.4% of their families reported patients' problems of irritability. Meanwhile, both self-reported and family-reported irritability post-injury were significantly higher than those reported by the healthy subjects. When evaluating two sub-components of irritability, respectively, both family- and self-reported post-injury annoyance were significantly higher than the pre-injury one, while the self-reported post-injury verbal aggression was not. CONCLUSIONS: TBI patients have remarkable problems of irritability after injuries. Specifically, the results showed that annoyance might be the main characteristic of irritability in TBI patients and patients themselves might be unaware of their verbal aggression post-injury. Hence, it is merited to pay more attention to the annoyance of the patients with TBI and to the reports from significant caregivers when evaluating TBI patients' irritability in clinical settings.

Intravoxel Incoherent Motion-Diffusion-Weighted MRI for Investigation of Delayed Graft Function Immediately after Kidney Transplantation.

Purpose: A non-invasive way of assessing post-transplant renal graft function has been needed. This study aimed to assess the micro-structural and micro-functional status of graft kidneys by using intravoxel incoherent motion- (IVIM-) diffusion-weighted imaging (DWI) to investigate delayed graft function (DGF) immediately after transplantation. Method: A prospective study was conducted on 37 patients, 14 with early graft function (EGF) and 23 with DGF (9 with complication, 14 without) who underwent IVIM-DWI, most often within 1-7 days after kidney transplantation. A total of 37 cases were collected and all the participants have been well-informed and signed their consents. In addition, the study conducted in this paper was approved by the Ethics Committee of Clinical Research, Taichung Veterans General Hospital (IRB number: CE14065). Using biexponential analysis of slow diffusion coefficient (D slow), fast diffusion coefficient (D fast), and perfusion fraction was performed. The apparent diffusion coefficient (ADC) was calculated by use of a monoexponential model. All parameters were measured from three different regions-of-interest (ROI), covering the entire renal parenchyma, cortex, and medulla. Results: D slow, perfusion fraction, and ADC were significantly higher in patients with EGF than DGF (all p values values <0.001). Especially, ADC measured from ROI covering the entire kidney parenchyma had the best cut-off value (1.93µm2/msec) with the highest area under the receiver operating characteristic curve (AUC 0.943) in differentiating EGF from DGF. For analysis of pair-wise differences, only the perfusion fraction values, measured from the ROI covering the renal cortex, were significantly higher in 14 DGF patients with no complications than in the 9 DGF patients with complications, with the best cut-off value of 12.3% and the AUC of 0.844. Conclusion: Noninvasive IVIM-DWI reliably differentiates DGF from EGF after kidney transplantation, and it may aid in identifying posttransplant complications and indications for renal biopsy.

Early parenchymal contrast extravasation predicts subsequent hemorrhage progression, clinical deterioration, and need for surgery in patients with traumatic cerebral contusion.

BACKGROUND: This study aimed to identify early radiologic signs that are predictive of hemorrhage progression and clinical deterioration in patients with traumatic cerebral contusion. We hypothesized that contrast extravasation (CE) and blood-brain barrier disruption might be associated with hemorrhage progression, brain edema, and clinical deterioration in these patients. METHODS: Twenty-two patients with traumatic cerebral contusion (diagnosed on initial noncontrast head computed tomography [CT]) who initially did not require surgical intervention were enrolled in this study. Contrast-enhanced and perfusion CT scans were performed within 6 hours of injury, and follow-up noncontrast CT scans were performed at 24 hours and 72 hours. RESULTS: In each noncontrast CT scan, the volumes of the contusion hemorrhage and edema were calculated using computerized planimetric techniques. The initial Glasgow Coma Scale, hemorrhage progression, clinical deterioration, and the need for subsequent surgery were recorded. The early radiologic findings were compared with these parameters and functional outcome at 6 months to identify predictive radiologic signs. CE was present in 9 of 22 patients (41%) and was highly associated with hemorrhage progression (p < 0.05), clinical deterioration (p < 0.01), and need for subsequent surgery (p < 0.01). In addition, patients with CE had a greater volume of edema at 24 hours (p < 0.01) and 72 hours (p < 0.01) than those who did not have CE. However, CE was not found to be associated with poor outcome. CONCLUSIONS: Early parenchymal CE is associated with hemorrhage progression, cerebral edema, clinical deterioration, and need for subsequent surgery. These patients should be monitored closely, and early surgery may be needed if deterioration occurs. Further elucidation of the pathophysiology is needed to formulate effective treatment for these high-risk patients.

Long-Term Presentation of Postconcussion Symptoms and Associated Factors: Analysis of Latent Class Modeling.

OBJECTIVE: Postconcussion symptoms (PCS) are commonly reported by patients with mild traumatic brain injury (MTBI). Although PCS significantly recovered by 3-month postinjury, a number of patients still experienced persistent PCS for >1 year. As few researchers investigated long-term PCS endorsement, the present study thus aims to show the latent structure of long-term PCS and further uncover its associating factors. METHODS: In total, 110 patients with MTBI and 32 healthy participants were prospectively enrolled. PCS was evaluated at 2 weeks and long-term evaluations (mean = 2.90 years) after MTBI. In addition, cognitive functions, which include memory, executive function, and information processing, and emotional disturbances, which include depression, anxiety, and irritability, were also examined at 2-week postinjury. RESULTS: Patients reported significantly more PCS at 2-week postinjury than healthy participants did, but PCS significantly improved at long-term evaluations when comparing with PCS at acute stage after MTBI. Both of PCS at 2 weeks and long-term evaluations can be further subdivided into subgroups based on the severity of PCS, in which specific PCS (e.g., fatigue, loss of energy, insomnia, slowness of information processing, irritability, and blurred vision) can be well differentiated among subgroups at long-term evaluations. CONCLUSIONS: This study directly showed the characteristics of long-term PCS and associating factors. It further evidenced that specific physical, cognitive, and emotional symptoms might be determinant to identify the subgroups of patients with long-term PCS endorsement.

Clinical significance of posterior circulation changes after revascularization in patients with moyamoya disease.

OBJECTIVE: It has been noted that the posterior circulation serves as an important source of collateral blood supply in moyamoya disease. Since most of the literature has focused on non-operative cases and many symptomatic patients receive surgical revascularization, we evaluated the posterior circulation changes after revascularization and found that progressive posterior cerebral artery (PCA) steno-occlusive changes after revascularization caused cerebral hemodynamic compromise and clinical deterioration in a significant portion of patients. METHODS: Twenty-three moyamoya disease patients with ischemic presentation who received revascularization with complete angiography and xenon CT during a minimum of 3 years' clinical follow-up were enrolled. Revascularization was performed in 38 hemispheres. Pre- and postoperative angiography were reviewed to determine the internal carotid artery (ICA) stage, PCA stage, leptomeningeal collateral (LMC) grade, and Matsushima synangiosis grade. The postoperative regional cerebral blood flow (CBF) and cerebral vascular reserve (CVR) were recorded and correlated with angiographic findings and clinical outcome. RESULTS: Progression of ICA staging was noted in 23 sides (55.2%), and progression of PCA staging was noted in 18 sides (47.4%). Among the 18 cases of PCA stage progression, an associated decrease in LMC grade was noted in 12 sides (66.7%). These changes were associated with decreased regional CBF and CVR, which also explained the recurrent ischemic symptoms in 27.8% of these patients. In contrast, LMC grade increased in 15 (65.2%) sides of patients with ICA progression. CONCLUSIONS: Progressive steno-occlusive change in the PCA after revascularization is associated with a reduction in LMC blood flow and cerebral ischemia in moyamoya patients. This phenomenon might cause recurrent ischemic symptoms in 27.8% of patients.

Decompressive craniectomy as the primary surgical intervention for hemorrhagic contusion.

The standard surgical treatment of hemorrhagic cerebral contusion is craniotomy with evacuation of the focal lesion. We assessed the safety and feasibility of performing decompressive craniectomy and duraplasty as the primary surgical intervention in this group of patients. Fifty-four consecutive patients with Glasgow Coma Scale (GCS) scores of less than or equal to 8, a frontal or temporal hemorrhagic contusion greater than 20 cm(3) in volume, and a midline shift of at least 5 mm or cisternal compression on computer tomography (CT) scan were studied. Sixteen (29.7%) underwent traditional craniotomy with hematoma evacuation, and 38 (70.4%) underwent craniectomy as the primary surgical treatment. Mortality, reoperation rate, Glasgow Outcome Scale-Extended (GOSE) scores, and length of stay in both the acute care and rehabilitation phase were compared between these two groups. Mortality (13.2% vs. 25.0%) and reoperation rate (7.9% vs. 37.5%) were lower in the craniectomy group, whereas the length of stay in both the acute care setting and the rehabilitation phase were similar between these two groups. The craniectomy group also had better GOSE score (5.55 vs. 3.56) at 6 months. Decompressive craniectomy is safe and effective as the primary surgical intervention for treatment of hemorrhagic contusion. This study also suggests that patient with hemorrhagic contusion can possibly have better outcome after craniectomy than other subgroup of patients with severe traumatic brain injury.

Cushing response-based warning system for intensive care of brain-injured patients.

OBJECTIVE: Cushing response (CR) is categorized. Wavelet transform (WT) and decision tree (DT) are utilized to analyze physiological signals from neurocritical patients. A warning model is built for recognition of CR, real-time evaluation of intracranial condition and prediction of neurological outcome. METHODS: Physiological signals of neurocritical patients are preprocessed by WT and compressed by linear regression. An algorithm labels each segment as pathological, physiological, negative or uncertain CR. The DT identifies CR. Continuous data input to the established DT predicts condition at that moment and following outcome. RESULTS: From 33 neurocritical patients, 422,524 sets of physiological signals were collected. The cross-validation scores of DT ranged from 0.562 to 0.579 with averaged accuracy rate 60.6% (3.5-98.1%). The model correctly predicted the outcome of the training group, 87.9% in accuracy. The ratios of pathological CR were 9.3 ±â€¯16.6%, 74.2 ±â€¯29.7% and 99.7 ±â€¯0.3% in patients of good, coma and death groups, respectively. The prediction accuracy for a test set of 103 patients reached 81.6%. CONCLUSIONS: Cushing response categorization helps in identifying critical conditions and predicting outcome. SIGNIFICANCE: A novel concept of four categories of Cushing response is proposed to represent broader ranges of intracranial change.

Iatrogenic Effect? Cautions when Utilizing an Early Health Education for Post-concussion Symptoms.

OBJECTIVE: Patients with mild traumatic brain injury (MTBI) usually suffer from the post-concussion symptoms (PCS). PCS could recover by 3 months post-injury, but some patients still persistently complain of those symptoms for years. Accordingly, the Chang-Gung University Brief Intervention for Post-Concussion Symptoms (CGU-BIPCS) was developed to intervene PCS based on the established advantages of health education. This prospective study thus aims to evaluate the effectiveness of CGU-BIPCS for patients with MTBI. METHODS: A total of 130 participants, which included 53 healthy participants and 77 patients with MTBI. Patients were further subdivided as two groups: "regular intervention" (RI) and "health education intervention" (EI). PCS of patients with MTBI were respectively evaluated at 2 weeks and 3 months post-injury, and symptoms of healthy participants were also examined. RESULTS: Both patients in RI and EI reported significantly more PCS than healthy participants did at 2 weeks and 3 months post-injury but less PCS at 3 months than at 2 weeks post-injury. However, the PCS endorsement of patients in RI and EI were not significantly different. In addition, more patients in EI reported significantly PCS deterioration than patients in RI did at 3 months post-injury. CONCLUSIONS: Although establishing the effectiveness of CGU-BIPCS was unsuccessful in this study, it is further suggested that a potential iatrogenic effect from this kind of early interventions should never be overlooked.

Disentangling geographical, biotic, and abiotic drivers of plant diversity in neotropical Ruellia (Acanthaceae).

It has long been hypothesized that biotic interactions are important drivers of biodiversity evolution, yet such interactions have been relatively less studied than abiotic factors owing to the inherent complexity in and the number of types of such interactions. Amongst the most prominent of biotic interactions worldwide are those between plants and pollinators. In the Neotropics, the most biodiverse region on Earth, hummingbird and bee pollination have contributed substantially to plant fitness. Using comparative methods, we test the macroevolutionary consequences of bird and bee pollination within a species rich lineage of flowering plants: Ruellia. We additionally explore impacts of species occupancy of ever-wet rainforests vs. dry ecosystems including cerrado and seasonally dry tropical forests. We compared outcomes based on two different methods of model selection: a traditional approach that utilizes a series of transitive likelihood ratio tests as well as a weighted model averaging approach. Analyses yield evidence for increased net diversification rates among Neotropical Ruellia (compared to Paleotropical lineages) as well as among hummingbird-adapted species. In contrast, we recovered no evidence of higher diversification rates among either bee- or non-bee-adapted lineages and no evidence for higher rates among wet or dry habitat lineages. Understanding fully the factors that have contributed to biases in biodiversity across the planet will ultimately depend upon incorporating knowledge of biotic interactions as well as connecting microevolutionary processes to macroevolutionary patterns.