Commissural Inter-M1 Cortico-cortical Evoked Potential: A Proof of Concept Report.

BACKGROUND: Intraoperative neuromonitoring of motor functions experienced a dramatical revolution in the last years thanks to significant advances in anesthesiology procedures and both preoperative and intraoperative mapping techniques. Asleep, awake, and combined intraoperative mapping techniques were responsible for an improvement in the functional outcomes in neurosurgery, providing reliable and reproducible mapping of both projection and association fibers involved in motor control. METHODS: We report inter-M1 cortico-cortical evoked potential (CCEP) recording during asleep resection of a bilateral parasagittal meningioma with intraoperative neuromonitoring and motor mapping. RESULTS: CCEPs were recorded between both M1 cortices with bipolar stimulations of both supplementary motor areas (10.5-11.5 µV). CONCLUSIONS: Here, we provide evidence of intraoperative mapping of commissural fibres involved in motor control in a patient with asleep technique as well as a review of the potential tracts involved in the connectivity underlying the motor function.

Primary Lumbar Paraganglioma: Clinical, Radiologic, Surgical, and Histopathologic Characteristics from a Case Series of 13 Patients.

BACKGROUND: Paragangliomas are uncommon neuroendocrine tumors, rarely occurring in the lumbar spine. Primary lumbar paragangliomas are prominently vascularized, can present variably, and pose both diagnostic and surgical challenges. We report on a large case series with long-term follow-up and intraoperative footage to characterize the natural history, diagnostic approach, and operative approach to this rare surgical disease. METHODS: This is a single-center, retrospective cohort study including all patients with histologically confirmed primary lumbar paraganglioma treated at our tertiary neurosurgical center between 1997 and 2018. Clinical, radiologic, surgical, and histologic data were collected from medical records. RESULTS: There were 13 cases of primary lumbar paraganglioma (8 men [61.5%], 5 women [38.5%]; mean age, 51.3 years; range, 33.2-68.9 years). Symptom duration correlated with tumor size (Spearman r = 0.735, P = 0.01). The main presenting symptoms were lower back pain and radiculopathy, often long-standing with recent deterioration. Seven patients (53.8%) were admitted as emergency cases, including 3 with cauda equina syndrome. Preoperative differential diagnoses included nerve sheath tumor, ependymoma, meningioma, and disk herniation. The mean Ki-67 mitotic index was 5.7% (range, 1%-10%). Surgical resection improved pain in 8 of 13 patients (61.5%) and weakness improved in 5 of 5 patients (100%). CONCLUSIONS: Primary lumbar paragangliomas are rare neoplasms of the cauda equina that typically progress slowly but may also present acutely. They are often related to the filum terminale, which should be resected prior to other attachments intraoperatively to prevent displacement of the tumor out of view. Total resection can be curative, and long-term follow-up in this series found no recurrence.

Lesson of the month 1: Massive spontaneous haematomas in an elderly man.

A 73-year-old man presented with bilateral leg pain and swelling, and no history of trauma or bleeding disorders. Clinical examination, biochemistry and magnetic resonance imaging of the thighs were suggestive of muscle haematomas. These progressed significantly during the admission, requiring blood transfusion. Normal vascular anatomy on computed tomography, renal and liver function, and absence of infection made a bleeding diathesis more likely. This may be caused by coagulation defects, platelet disorders and vascular fragility. An undetectable serum ascorbic acid level confirmed the clinical suspicion of scurvy, and administration of vitamin C resulted in rapid improvement. Our case provides a structured approach to the diagnosis of bleeding disorders and scurvy, a treatable and potentially fatal disease which is often forgotten.

Quantitative fetal fibronectin predicts preterm birth in women with bulging fetal membranes.

OBJECTIVE: To assess the predictive value of quantitative fetal fibronectin (fFN) concentration in cervicovaginal fluid for spontaneous preterm birth in women with bulging fetal membranes. STUDY DESIGN: This was a prospective observational study from five UK tertiary centres of a cohort of women with singleton pregnancy and bulging fetal membranes presenting between 18 and 32 weeks of gestation (n=62), in the period 2010-2014. fFN concentrations in cervicovaginal fluid were measured both quantitatively and qualitatively at presentation in all women. Predictive statistics and receiver operating characteristic (ROC) curves were calculated for both tests to predict spontaneous preterm birth within 14 days from testing and before 34 weeks of gestation. RESULTS: 62 eligible women with bulging fetal membranes were recruited from screening of 2571 women at high risk of preterm birth. The median gestational age was 24(+0) (LQ-UQ, 21(+2)-25(+3)) at presentation and 34(+4) (25(+2)-39(+0)) at delivery, with a median time from testing to delivery of 58 days (17-110). Concentration of quantitative fFN at presentation correlated negatively with time to delivery (Spearman's rs=-0.615, p<0.001). The area under the ROC curve for quantitative fFN testing was 0.81 (95% CI 0.69-0.94) for prediction of spontaneous preterm birth within 14 days, and 0.84 (0.73-0.95) before 34 weeks of gestation. CONCLUSION: Quantitative fFN has a role in predicting spontaneous preterm birth even in women with bulging fetal membranes, suggesting that fFN leakage could potentially be an active process. This may aid the clinical management of this high-risk group in the future.

Old complication, new presentation: a case of the spleen taking the bullet.

We report a case of a 43-year-old man who presented to the accident and emergency department with acute abdominal pain. Ultrasound investigation showed non-specific splenic pathology and treatment for a splenic abscess was started. The patient later described a history of episodic, cardiac-sounding chest pain occurring at rest, the most recent case of which (6 days prior to admission) had been unusually severe. ECG showed anterior Q waves and aneurysm-type ST-T segment changes. Echocardiography, coupled with a CT scan of the abdomen, revealed the aetiology. The patient had sustained an anterolateral myocardial infarction, which had led to mural thrombus formation and secondary embolisation to the spleen, with no other end organ damage detected. The patient responded well to conservative management of the splenic infarct and initiation on the acute coronary syndrome pathway. Coronary angiography showed mild disease of the proximal left anterior descending artery. Cardiac MRI at 1 month confirmed an ischaemic aetiology.

Knowledge gaps and acceptability of abbreviated alcohol screening in general practice: a cross-sectional survey of hazardous and non-hazardous drinkers.

BACKGROUND: General practice provides a unique setting where hazardous alcohol consumption can be screened for and behavioural interventions can be implemented in a continuous care model. Our aim was to assess in a general practice population, the prevalence of hazardous drinking, the knowledge and attitudes surrounding alcohol, and the acceptability of brief interventions in alcohol. METHODS: A cross-sectional survey in a practice in South London, performed as part of a wider service evaluation. Questionnaires were offered to adult patients awaiting their appointments. Responses were stratified according to hazardous drinking, as per the abbreviated 'Alcohol Use Disorders Identification Test' (AUDIT-C). RESULTS: Of 179 respondents (30 % male), 34 % yielded an AUDIT-C ≥5 and 18 % reported that they never drink alcohol. Male and Caucasian patients were more likely to self-report hazardous drinking, who in turn were more likely to believe in the health benefits of moderate consumption. Little over half of patents thought that alcohol is a risk factor for cancer and were misinformed of its calorific content, suggesting two targets for future improvement. Patients' knowledge about what is a single 'unit' of alcohol was below that expected by random chance 66 % agreed that alcohol screening should feature in all GP consultations. CONCLUSIONS: While awareness of alcohol related health risks is generally good, future efforts may benefit from focusing on the association with cancer and calories. Our findings question the utility of the 'unit' system, as well as dissemination of suggested 'health benefits' of moderate consumption. General practice initiatives in screening and brief advice for alcohol deserve further study.