Quality of life scores in patients with unruptured cerebral aneurysm: Prospective cohort study.

BACKGROUND: Living with the diagnosis of an unruptured cerebral aneurysm can understandably cause distress to a patient. The goal of preventive treatment is to increase the number of years with good quality of life (QoL). OBJECTIVE: This study aimed to measure the effect of unruptured intracranial aneurysm treatment on change in QoL scores measured by the SF36 and EQ-5D-5L. METHODS: We prospectively collected SF36 and EQ-5D-5L survey data for patients with unruptured intracranial aneurysms at two time-points over 1 year between 2 treatment groups: observation and intervention (microsurgical and endovascular). Multivariable linear regression was used to examine treatment group differences in the mean change in scores from baseline to 1 year when adjusted for covariates. RESULTS: 92 patients were included in the observation group and 68 patients were included in the intervention group, for a total of 160 patients. The intervention group had lower SF36 total scores at baseline (p = 0.001). With multivariate linear regression models, the effect of treatment on mean change in SF36 total score from baseline to 1 year was not statistically significant (p = 0.4); similarly, there was no difference in mean change in EQ-5D-5L. CONCLUSION: In this large prospective study, preventive aneurysm treatment was not associated with a significant change in QoL score at 1 year compared to observation as measured by the SF36 and EQ-5D-5L. Further studies are needed to explore the lower QoL scores in patients seeking treatment and its impact on management decision making.

Cost-effectiveness analysis in patients with an unruptured cerebral aneurysm treated with observation or surgery.

OBJECTIVE: The main goal of preventive treatment of unruptured intracranial aneurysms (UIAs) is to avoid the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage. A comparison between the conservative approach and the surgical approach combining endovascular treatment and microsurgical clipping is currently lacking. This study aimed to conduct an updated evaluation of cost-effectiveness comparing the two approaches in patients with UIA. METHODS: A decision tree with a Markov model was developed. Quality-adjusted life-years (QALYs) associated with living with UIA before and after treatment were prospectively collected from a cohort of patients with UIA at a tertiary center. Other inputs were obtained from published literature. Using Monte Carlo simulation for patients aged 55, 65, and 75 years, the authors modeled the conservative management in comparison with preventive treatment. Different proportions of endovascular and microsurgical treatment were modeled to reflect existing practice variations between treatment centers. Outcomes were assessed in terms of QALYs. Sensitivity analyses to assess the model's robustness and completed threshold analyses to examine the influence of input parameters were performed. RESULTS: Preventive treatment of UIAs consistently led to higher utility. Models using a higher proportion of endovascular therapy were more cost-effective. Models with older cohorts were less cost-effective than those with younger cohorts. Treatment was cost-effective (willingness to pay < 100,000 USD/QALY) if the annual rupture risk exceeded a threshold between 0.8% and 1.9% in various models based on the proportion of endovascular treatment and cohort age. A higher proportion of endovascular treatments and younger age lowered this threshold, making the treatment of aneurysms with a lower risk of rupture more cost-effective. CONCLUSIONS: Preventive treatment of aneurysms led to higher utility compared with conservative management. Models with a higher proportion of endovascular treatment and younger patient age were most cost-effective.

A History of Diagnostic Investigations in Epilepsy Surgery.

Epilepsy surgery has progressed significantly in the last 150 years. Functional brain maps allowed for the localization of epileptogenic lesions based on seizure patterns, allowing surgeons like McEwan and Horsely to treat epilepsy surgically. Berger's electroencephalogram marked the first modality directly identifying epileptic abnormalities. Penfield and Jasper collaborated, as neurosurgeon and neurologist, to use EEG for surgery. Meanwhile, Wada developed the amobarbital test, improving the protection of language and memory. Talairach and Bancaud pioneered invasive monitoring of deep brain activity with stereoelectroencephalography before the computer age made CT and MRI possible. Looking forward, AI and robotics hold promise for further improving outcomes.

Impact of work hours and sleep on well-being and burnout for physicians-in-training: the Resident Activity Tracker Evaluation Study.

OBJECTIVE: The Resident Activity Tracker Evaluation (RATE) is a prospective observational study evaluating the impact of work hours, sleep and physical activity on resident well-being, burnout and job satisfaction. BACKGROUND: Physician burnout is common and its incidence is increasing. The impact of work hours and sleep on resident well-being and burnout remains elusive. Activity trackers are an innovative tool for measuring sleep and physical activity. METHODS: Residents were recruited from (i) general surgery and orthopaedics (SURG), (ii) internal medicine and neurology (MED) and (iii) anaesthesia and radiology (RCD). Groups 1 and 2 do not enforce restrictions on the duration of being on-call, and group 3 had restricted the duration of being on-call to 12 hours. Participants wore FitBit trackers for 14 days. Total hours worked, daily sleep, sleep on-call and daily steps were recorded. Participants completed validated surveys assessing self-reported well-being (Short-Form Health Survey), burnout (Maslach Burnout Inventory), and satisfaction with medicine. RESULTS: Surgical residents worked the most hours per week, followed by medical and RCD residents (SURG, 84.3 hours, 95% CI, 80.2-88.5; MED, 69.2 hours, 95% CI, 65.3-73.2; RCD, 52.2 hours, 95% CI, 48.2-56.1; p < 0.001). Surgical residents obtained fewer hours of sleep per day (SURG, 5.9 hours, 95% CI, 5.5-6.3; MED, 6.9 hours, 95% CI, 6.5-7.3; RCD, 6.8 hours, 95% CI, 5.6-7.2; p < 0.001). Nearly two-thirds of participants (61%) scored high burnout on the Maslach depersonalisation subscore. Total steps per day and well-being, burnout and job satisfaction were comparable between groups. Total hours worked, daily sleep and steps per day did not predict burnout or well-being. CONCLUSIONS: Work hours and average daily sleep did not affect burnout. Physical activity did not prevent burnout. Work hour restrictions may lead to increased sleep but may not affect resident burnout or well-being.

Factors predictive of symptomatic radiation injury after linear accelerator-based stereotactic radiosurgery for intracerebral arteriovenous malformations.

PURPOSE: To investigate predictive factors in the development of symptomatic radiation injury after treatment with linear accelerator-based stereotactic radiosurgery for intracerebral arteriovenous malformations and relate the findings to the conclusions drawn by Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC). METHODS AND MATERIALS: Archived plans for 73 patients who were treated at the British Columbia Cancer Agency were studied. Actuarial estimates of freedom from radiation injury were calculated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards models were used for analysis of incidence of radiation injury. Log-rank test was used to search for dosimetric parameters associated with freedom from radiation injury. RESULTS: Symptomatic radiation injury was exhibited by 14 of 73 patients (19.2%). Actuarial rate of symptomatic radiation injury was 23.0% at 4 years. Most patients (78.5%) had mild to moderate deficits according to Common Terminology Criteria for Adverse Events, version 4.0. On univariate analysis, lesion volume and diameter, dose to isocenter, and a V(x) for doses ≥8 Gy showed statistical significance. Only lesion diameter showed statistical significance (p < 0.05) in a multivariate model. According to the log-rank test, AVM volumes >5 cm(3) and diameters >30 mm were significantly associated with the risk of radiation injury (p < 0.01). The V(12) also showed strong association with the incidence of radiation injury. Actuarial incidence of radiation injury was 16.8% if V(12) was <28 cm(3) and 53.2% if >28 cm(3) (log-rank test, p = 0.001). CONCLUSIONS: This study confirms that the risk of developing symptomatic radiation injury after radiosurgery is related to lesion diameter and volume and irradiated volume. Results suggest a higher tolerance than proposed by QUANTEC. The widely differing findings reported in the literature, however, raise considerable uncertainties.

Utility of screening for blunt vascular neck injuries with computed tomographic angiography.

PURPOSE: To prospectively study the impact of implementing a computed tomographic angiography (CTA)-based screening protocol on the detected incidence and associated morbidity and mortality of blunt vascular neck injury (BVNI). METHODS: Consecutive blunt trauma patients admitted to a single tertiary trauma center and identified as at risk for BVNI underwent admission CTA using an eight-slice multi-detector computed tomography scanner. The detected incidence, morbidity, and mortality rates of BVNI were compared with those measured before CTA screening. A logistic regression model was also applied to further evaluate potential risk factors for BVNI. RESULTS: A total of 1,313 blunt trauma patients were evaluated. One hundred seventy screening CTAs were performed, of which 33 disclosed abnormalities. Twenty-three were evaluated angiographically, of which 15 were considered to have significant BVNIs, as were 4 of the 10 patients with abnormal CTAs and no angiogram. The incidence of angiographically proven BVNIs in our series was 1.1%. If four patients who were treated for BVNIs based on CTA alone are included, the incidence rises to 1.4%. This is significantly higher than the 0.17% incidence before screening (p < 0.001). In addition, the delayed stroke rate and injury-specific mortality fell significantly from 67% to 0% (p < 0.001) and 38% to 0% (p = 0.002), respectively. Overall mortality also fell significantly, from 38% to 10.5% (p = 0.049). Univariate logistic regression identified the presence of cervical spine injury as a significant predictor of BVNI (p < 0.001). CONCLUSION: CTA screening increases the detected incidence of BVNI 8-fold, with rates similar to angiographically based screening protocols. CTA screening significantly decreases BVNI-related morbidity and mortality in an efficient manner, underlying its utility in the early diagnosis of this injury.