Women in Neurosurgery: Historical Path to Self-Segregation and Proposal for an Integrated Future.

Despite the rising percentage of women accessing the medical profession over the last few decades, surgical specialties are still largely male-dominated; in particular, a remarkable gender disparity is evident in neurosurgery, where only 19% of practitioners are females. Although women may be reluctant to choose a challenging specialty like neurosurgery due to concerns around how to balance family and career, it must be admitted that prejudices against female neurosurgeons have been deeply rooted for long, prompting many to give up and switch track to less demanding subspecialties. Among those who have persisted, many, if not most, have experienced difficulties in career progression and received unequal treatment in comparison with their male counterparts. In 1989, a group of 8 female neurosurgeons founded Women in Neurosurgery (WINS), an organization that aimed to guarantee inclusivity in neurosurgery, encouraging a better and more egalitarian working environment. Thereafter, WINS sessions were regularly promoted at international conferences, offering female neurosurgeons a platform to report issues related to gender discrimination. Over recent years, the mission of WINS sessions in national and international conferences has taken an unexpected deviation; they have progressively become supplementary scientific sessions with only women neurosurgeons as speakers, thus paving the road to a form of self-segregation. This tendency has also resulted in the establishment of sections of only female neurosurgeons within some national societies. Although there remains a faction that fiercely supports the WINS mindset of reserved spaces for women, such segregation is an upsetting prospect for those who believe that science and professionalism have no gender; a growing part of the global neurosurgical community believes that the conception of a "female neurosurgery" and a "male neurosurgery" is misguided and counterproductive and consider the existence of the WINS as anachronistic and no longer necessary.

Observing separate spin and charge Fermi seas in a strongly correlated one-dimensional conductor.

An electron is usually considered to have only one form of kinetic energy, but could it have more, for its spin and charge, by exciting other electrons? In one dimension (1D), the physics of interacting electrons is captured well at low energies by the Tomonaga-Luttinger model, yet little has been observed experimentally beyond this linear regime. Here, we report on measurements of many-body modes in 1D gated wires using tunneling spectroscopy. We observe two parabolic dispersions, indicative of separate Fermi seas at high energies, associated with spin and charge excitations, together with the emergence of two additional 1D "replica" modes that strengthen with decreasing wire length. The interaction strength is varied by changing the amount of 1D intersubband screening by more than 45%. Our findings not only demonstrate the existence of spin-charge separation in the whole energy band outside the low-energy limit of the Tomonaga-Luttinger model but also set a constraint on the validity of the newer nonlinear Tomonaga-Luttinger theory.

Cranial nerve deficits in giant cavernous carotid aneurysms and their relation to aneurysm morphology and location.

BACKGROUND: Giant cavernous carotid aneurysms (GCCAs) usually exert substantial mass effect on adjacent intracavernous cranial nerves. Since predictors of cranial nerve deficits (CNDs) in patients with GCCA are unknown, we designed a study to identify associations between CND and GCCA morphology and the location of mass effect. METHODS: This study was based on data from the prospective clinical and imaging databases of the Giant Intracranial Aneurysm Registry. We used magnetic resonance imaging and digital subtraction angiography to examine GCCA volume, presence of partial thrombosis (PT), GCCA origins, and the location of mass effect. We also documented whether CND was present. RESULTS: We included 36 GCCA in 34 patients, which had been entered into the registry by eight participating centers between January 2009 and March 2016. The prevalence of CND was 69.4%, with one CND in 41.7% and more than one in 27.5%. The prevalence of PT was 33.3%. The aneurysm origin was most frequently located at the anterior genu (52.8%). The prevalence of CND did not differ between aneurysm origins (p = 0.29). Intracavernous mass effect was lateral in 58.3%, mixed medial/lateral in 27.8%, and purely medial in 13.9%. CND occurred significantly more often in GCCA with lateral (81.0%) or mixed medial/lateral (70.0%) mass effect than in GCCA with medial mass effect (20.0%; p = 0.03). After adjusting our data for the effects of the location of mass effect, we found no association between the prevalence of CND and aneurysm volume (odds ratio (OR) 1.30 (0.98-1.71); p = 0.07), the occurrence of PT (OR 0.64 (0.07-5.73); p = 0.69), or patient age (OR 1.02 (95% CI 0.95-1.09); p = 0.59). CONCLUSIONS: Distinguishing between medial versus lateral location of mass effect may be more helpful than measuring aneurysm volumes or examining aneurysm thrombosis in understanding why some patients with GCCA present with CND while others do not. CLINICAL TRIAL REGISTRATION NO: NCT02066493 ( clinicaltrials.gov ).

[Nerve injuries and traumatic lesions of the brachial plexus : Imaging diagnostics and therapeutic options]. / Nervenverletzungen und traumatische Läsionen des Plexus brachialis : Bildgebende Diagnostik und therapeutische Optionen.

CLINICAL/METHODICAL ISSUE: Traumatic lesions of peripheral nerves and the brachial plexus are feared complications because they frequently result in severe functional impairment. The prognosis is greatly dependent on the correct early diagnosis and the right choice of treatment regimen. It is important to distinguish between open and closed injuries. STANDARD RADIOLOGICAL METHODS: Initial imaging must critically evaluate or prove nerve continuity and is commonly achieved by high-resolution ultrasonography. During the further course, reactive soft tissue alterations, such as constrictive scarring or neuroma formation can be detected. In the case of deep nerve and plexus injuries this can be excellently achieved by dedicated magnetic resonance neurography (MRN) sequences. METHODICAL INNOVATIONS: The signal yield from brachial plexus imaging can be critically enhanced by the use of dedicated surface coil arrays. Furthermore, diffusion tensor imaging (DTI) may enable the regeneration potential of a nerve lesion to be recognized in the future. PERFORMANCE: Multiple reports have shown that neurosonography enables a precise evaluation of peripheral nerve structures (up to 90% sensitivity and 95% specificity in nerve transection) and that the method can critically impact on therapeutic decision-making in 60%. Currently, there are only few quantitative data on the exact performance of MRN in traumatic nerve lesions; however, individual reports indicate a high level of agreement with intraoperative findings. PRACTICAL RECOMMENDATIONS: In the initial work-up, especially in the case of peripheral, superficial and lesser nerve injuries, neurosonography is the preferred imaging approach to evaluate nerve integrity and the extent of nerve lesions. In the case of extensive nerve injury of proximal nerves and structures of the plexus as well as in the case of suspected root avulsion MRN is the method of choice.

Prognostic models based on patient snapshots and time windows: Predicting disease progression to assisted ventilation in Amyotrophic Lateral Sclerosis.

Amyotrophic Lateral Sclerosis (ALS) is a devastating disease and the most common neurodegenerative disorder of young adults. ALS patients present a rapidly progressive motor weakness. This usually leads to death in a few years by respiratory failure. The correct prediction of respiratory insufficiency is thus key for patient management. In this context, we propose an innovative approach for prognostic prediction based on patient snapshots and time windows. We first cluster temporally-related tests to obtain snapshots of the patient's condition at a given time (patient snapshots). Then we use the snapshots to predict the probability of an ALS patient to require assisted ventilation after k days from the time of clinical evaluation (time window). This probability is based on the patient's current condition, evaluated using clinical features, including functional impairment assessments and a complete set of respiratory tests. The prognostic models include three temporal windows allowing to perform short, medium and long term prognosis regarding progression to assisted ventilation. Experimental results show an area under the receiver operating characteristics curve (AUC) in the test set of approximately 79% for time windows of 90, 180 and 365 days. Creating patient snapshots using hierarchical clustering with constraints outperforms the state of the art, and the proposed prognostic model becomes the first non population-based approach for prognostic prediction in ALS. The results are promising and should enhance the current clinical practice, largely supported by non-standardized tests and clinicians' experience.

Iatrogenic lesions of peripheral nerves.

Iatrogenic nerve lesions (INLs) are an integral part of peripheral neurology and require dedicated neurologists to manage them. INLs of peripheral nerves are most frequently caused by surgery, immobilization, injections, radiation, or drugs. Early recognition and diagnosis is important not to delay appropriate therapeutic measures and to improve the outcome. Treatment can be causative or symptomatic, conservative, or surgical. Rehabilitative measures play a key role in the conservative treatment, but the point at which an INL requires surgical intervention should not be missed or delayed. This is why INLs require close multiprofessional monitoring and continuous re-evaluation of the therapeutic effect. With increasing number of surgical interventions and increasing number of drugs applied, it is quite likely that the prevalence of INLs will further increase. To provide an optimal management, more studies about the frequency of the various INLs and studies evaluating therapies need to be conducted. Management of INLs can be particularly improved if those confronted with INLs get state-of-the-art education and advanced training about INLs. Management and outcome of INLs can be further improved if the multiprofessional interplay is optimized and adapted to the needs of the patient, the healthcare system, and those responsible for sustaining medical infrastructure.

Image guided aneurysm surgery in a Brainsuite® ioMRI Miyabi 1.5 T environment.

OBJECTIVE: Current literature only gives sparse account of aneurysm surgery in an intraoperative MRI environment. After installation of a BrainSuite(®) ioMRI Miyabi 1.5 T at our institution the aim of the present preliminary study was to evaluate feasibility, pros and cons of aneurysm surgery in this special setting. MATERIAL AND METHODS: Since February 2009, during a 3 months period we performed elective image guided aneurysm surgery in 4 ACM and 1 ACOM aneurysm (four patients) in this ioMRI setting. The patients' heads were rigidly fixed in the Noras 8-Channel OR Head Coil. Our imaging protocol included MP-RAGE, T2-TSE axial, TOF-MRA and diffusion-/perfusion-imaging immediately before surgery and after clip application. Presurgical 3D-planning was performed using the iPlan®-Software. RESULTS: All five aneurysms were operated without temporary clipping. There were no intra- or postoperative complications. Patient positioning and head fixation with the integrated Noras Head Clamp was feasible, but there were significant limitations particularly with regard to more complex approaches and patient physiognomy. Image quality especially TOF-MRA was good in 4, insufficient in 1 aneurysm. Presurgical planning especially vessel extraction from TOF-MRA was possible but certainly needs significant future improvement. Diffusion- and perfusion weighted examinations yielded good image quality. CONCLUSION: Our limited experience is encouraging so far. Further improvement particularly concerning flexibility of patient positioning and presurgical 3D-planning for vascular procedures is most necessary. As a future perspective image guided aneurysm surgery in an ioMRI-environment may be helpful especially in complex aneurysms and provide neurosurgeons and neuroanaesthesiologists with additional information about cerebral haemodynamics and perfusion pattern in the vascular territory distal to the target vessel.

Herpes genital / Genital herpes

O herpes genital é uma doença infectocontagiosa sujeita a recidivas, tendo como agente etiológico duas cepas diferentes do vírus herpes simples (HSV), o tipo 1 (HSV-1) e o tipo 2 (HSV-2). A grande maioria dos casos de herpes genital é causada pelo HSV-2, embora a prevalência do HSV-1 esteja em ascensão, principalmente na população jovem e devido à prática de sexo oral. A manifestação clínica pode ser primária ou recorrente, esta última acontecendo por reativação viral. O diagnóstico é feito pelas características clínicas associadas às confirmações laboratoriais da infecção. Diversos estudos clínicos e epidemiológicos demonstram a sinergia entre herpes genital e aids. Na gravidez, a grande preocupação acerca da infecção pelo HSV refere-se à morbidadee à mortalidade associadas à infecção neonatal. Atualmente não existe nenhum tratamento eficaz na cura do herpes genital, mas alguns medicamentos antivirais são capazes de diminuir o tempo da doença e prevenir as erupções. A maioria dos esforços para combater a infecção herpética genital concentrase no desenvolvimento de vacinas.

Genital herpes is an infectious disease subject to recurrent crises, with the etiologic agent of two different strains of herpes simplex virus (HSV), the type 1 (HSV-1) and type 2 (HSV-2). The vast majority of genital herpes cases is caused by HSV-2, although the prevalence of HSV-1 is on the rise, especially in young population and due to oral sex. The clinical manifestations may be primary or recurrent, the latter going on viral reactivation. The diagnosis is made by the clinical characteristics associated with laboratory confirmation of infection. Several epidemiological and clinical studies demonstrate the synergybetween genital herpes and aids. In pregnancy, the major concern about HSV infection refers to the morbidity and mortality associated with neonatal infection. Currently, there is no treatment capable of curing genital herpes, but some antiviral drugs are able to decrease the duration of the disease and prevent flares. Most efforts to combat genital herpes infection are focused on vaccine development.

[Knowledge, conduct and opinions of health professionals concerning confidentiality at a hospital]. / Conocimientos, comportamientos y opiniones de los profesionales sanitarios de un hospital en relación a la confidencialidad.

BACKGROUND: To analyse the knowledge, conduct and opinions concerning confidentiality of the medical and nursing personnel who attended the 13 seminars given on this subject at the Virgen del Camino Hospital in Pamplona in the year 2002. METHODS: Distribution before the start of each seminar of a survey of 11 closed questions to be completed anonymously. RESULTS: Ninety-three percent (93.0%) of the 244 professionals attending the seminars responded to the survey (128 doctors and 99 nurses). Ninety-two point one percent (92.1%) of the professionals understand what privacy is, but 58.1% do not know any of the laws that regulate it. Eighty-seven point five percent (87.5%) know when it is legitimate to access the data on a patient, but contrary conduct is recognise in a percentage that increases with age, from 12.5% in the group under 31 years old to 51.9% in those over 50 years of age. More correct practices were recollected amongst nursing personnel even when they show less theoretical knowledge about these questions. Forty-nine point seven percent (49.7%) of the professionals would join another centre if they wanted their diagnosis not to be divulged amongst their colleagues, and 92.2% consider informal comments made in the corridors to be the most frequent way of breaking confidentiality in the hospital. CONCLUSION: It seems timely to call attention to ethical and legal responsibility in our hospital and to encourage reflection amongst professional about this questions of confidentiality in order to improve this key dimension of health care.

[Implantation of a computerised clinical history: survey on the degree of utilisation and satisfaction in a tertiary hospital]. / Implantación de una historia clínica informatizada: encuesta sobre el grado de utilización y satisfacción en un hospital terciario.

BACKGROUND: To assess the utilization of an electronic medical record (EMR), the degree of satisfaction with this tool, as well as to detect problems in its utilization, in a tertiary hospital in Spain. METHODS: A survey was sent by mail to all physicians in the Virgen del Camino Hospital in Pamplona, Spain. RESULTS: Out of 445 staff physicians, 174 answered the survey (39%). Seventy-nine percent considered that the EMR is better than the traditional, paper-based medical record. Sixty-one percent used the EMR for consultation and to introduce clinical data in a regular way. Fifty-five percent agreed that the EMR has advantages for the patient. The main problems detected are a loss in confidentiality, lack of time, insufficient number of computers, and inadequate training. Ninety percent answered that EMR implementation should be continued and only 6% are dissatisfied with the computer application. CONCLUSIONS: There is a high degree of utilization of the EMR in the Virgen del Camino Hospital. Measures should be implemented to resolve the problems detected in this survey.