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1.
Neurosurgery ; 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32140720

RESUMO

Systematic reviews and meta-analyses in the neurosurgical literature have surged in popularity over the last decade. It is our concern that, without a renewed effort to critically interpret and appraise these studies as high or low quality, we run the risk of the quality and value of evidence-based medicine in neurosurgery being misinterpreted. Correspondingly, we have outlined 4 major domains to target in interpreting neurosurgical systematic reviews and meta-analyses based on the lessons learned by a collaboration of clinicians and academics summarized as 4 pearls. The domains of (1) heterogeneity, (2) modeling, (3) certainty, and (4) bias in neurosurgical systematic reviews and meta-analyses were identified as aspects in which the authors' approaches have changed over time to improve robustness and transparency. Examples of how and why these pearls were adapted were provided in areas of cranial neuralgia, spine, pediatric, and neuro-oncology to demonstrate how neurosurgical readers and writers may improve their interpretation of these domains. The incorporation of these pearls into practice will empower neurosurgical academics to effectively interpret systematic reviews and meta-analyses, enhancing the quality of our evidence-based medicine literature while maintaining a critical focus on the needs of the individual patients in neurosurgery.

2.
Neurosurg Rev ; 43(3): 957-966, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31041618

RESUMO

Rathke's cleft cysts (RCCs) are benign growths of the embryological Rathke's pouch. Surgical decompression provides effective symptomatic relief in most cases; however, the effect of gross total resection (GTR) of the cyst wall on recurrence, as well as pituitary function, is unclear. The aim of this meta-analysis was to pool the current literature and ascertain the recurrence control afforded by GTR of the cyst wall compared with subtotal resection (STR). Searches of seven electronic databases from inception to January 2019 were conducted following PRISMA guidelines, resulting in 476 articles to be screened. Outcomes were analyzed using meta-analysis of proportions. A total of 10 retrospective cohort studies satisfied selection criteria, describing 655 surgically managed RCC cases, with 254 (39%) and 401 (61%) achieving GTR and STR of the cyst wall, respectively. GTR was associated with significantly reduced overall RCC recurrence by fixed-effects (FE) modeling (RR, 0.66; 95% CI, 0.45-0.96), but not by random effects (RE) modeling (RR, 0.75; 95% CI, 0.51-1.12). Based on both models, GTR was associated with significantly reduced symptomatic recurrence (RE model, RR, 0.37, 95% CI, 0.14-0.95) and significantly increased postoperative diabetes insipidus (RE model, RR, 2.60; 95% CI, 1.34-5.03). There was insufficient data to evaluate other pituitary axes in this context. The current evidence indicates that GTR of the RCC cyst wall has the potential to affect the incidence of overall and symptomatic RCC recurrences, as well as drive postoperative DI incidence. However, expectations of clinical and pragmatic benefit following cyst wall resection should be titrated carefully against the potential for postoperative and pituitary morbidities which currently remain poorly defined. Greater granularity is required to understand all factors that can influence recurrence and quality of life when evaluating resection of RCC.

3.
Pituitary ; 22(6): 633-639, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31620953

RESUMO

PURPOSE: This case series evaluates the surgical management of granular cell tumor (GCT) of the sellar region. This rare entity presents a unique diagnostic and surgical challenge. METHODS: Institutional neuropathology databases at Brigham and Women's Hospital and Massachusetts General Hospital were searched for cases with a tissue diagnosis of GCT, and with a location in the sellar region. Patient, treatment, tumor, and follow-up data were extracted. RESULTS: Three patients had a diagnosis of GCT of the sellar region occurring over an 18-year period. All three patients were followed postoperatively at our multidisciplinary pituitary center (median follow-up = 30 months; range 12-30 months). Hormonal disturbances, an incidental lesion requiring diagnosis, and neurological symptoms were indications for surgery in these patients. Two patients underwent a craniotomy and one underwent endoscopic transsphenoidal surgery. All three patients were free of tumor recurrence at last follow-up. In one case tested, positive thyroid transcription factor-1 (TTF-1) immunohistochemistry was observed. CONCLUSION: GCT is generally a benign tumor of the sellar region. Surgical resection is the standard treatment, more recently with transsphenoidal surgery when indicated. Surgical resection results in optimal outcome for patients.


Assuntos
Tumor de Células Granulares/diagnóstico , Tumor de Células Granulares/cirurgia , Neoplasias Hipofisárias/diagnóstico , Neoplasias Hipofisárias/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/cirurgia , Doenças da Hipófise/diagnóstico , Doenças da Hipófise/cirurgia
4.
World Neurosurg ; 121: e223-e229, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30261394

RESUMO

OBJECTIVE: Readmission and reoperation are risks in the resection of benign cranial nerve tumors (BCNTs). This report analyzes the impact of patient-level and surgical factors on these adverse outcomes. METHODS: This retrospective cohort review comprised patients with a diagnosis of BCNT enrolled in the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2015. Multivariate logistic regression was used to determine the impact of select medical and operative factors on the primary outcomes of readmission and reoperation within 30 days, adjusted for relevant covariates. RESULTS: We identified 996 patients who underwent resection of a BCNT. The most frequent major complications were readmission (11%), reoperation (8%), surgical site infections (2.6%), and venous thromboembolism (1.5%). The most frequent indications for readmission were management of infection (2.5%), cerebrospinal fluid leak (2.3%), and hydrocephalus (0.5%). Repair of cranial and meningeal defects (3.0%), correction of lagophthalmos (1.2%), and repair of middle ear defects (1.0%) were the most common indications for reoperation. Logistic regression revealed that extremes of age were associated with readmission, whereas preoperative steroid usage, long operative time, and postoperative length of stay >3 days were associated with reoperation (P < 0.05). Obesity trended toward an association with readmission and reoperation. CONCLUSIONS: Extremes of age were associated with readmission; preoperative steroid use, long operative time, and postoperative length of stay >3 days were associated with reoperation. Surgeons should consider these factors when assessing risk of postoperative complications for BCNTs.


Assuntos
Neoplasias dos Nervos Cranianos/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Adulto , Neoplasias dos Nervos Cranianos/epidemiologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Neuroma Acústico/epidemiologia , Neuroma Acústico/cirurgia , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação/estatística & dados numéricos , Fatores de Risco , Esteroides/uso terapêutico , Estados Unidos/epidemiologia
5.
J Neurosurg ; : 1-10, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-30497144

RESUMO

OBJECTIVELoss of pituitary function due to nonfunctional pituitary adenoma (NFPA) may be due to compression of the pituitary gland. It has been proposed that the size of the gland and relative perioperative gland expansion may relate to recovery of pituitary function, but the extent of this is unclear. This study aims to assess temporal changes in hormonal function after transsphenoidal resection of NFPA and the relationship between gland reexpansion and endocrine recovery.METHODSPatients who underwent endoscopic transsphenoidal surgery by a single surgeon for resection of a nonfunctional macroadenoma were selected for inclusion. Patients with prior pituitary surgery or radiosurgery were excluded. Patient characteristics and endocrine function were extracted by chart review. Volumetric segmentation of the pre- and postoperative (≥ 6 months) pituitary gland was performed using preoperative and long-term postoperative MR images. The relationship between endocrine function over time and clinical attributes, including gland volume, were examined.RESULTSOne hundred sixty eligible patients were identified, of whom 47.5% were female; 56.9% of patients had anterior pituitary hormone deficits preoperatively. The median tumor diameter and gland volume preoperatively were 22.5 mm (interquartile range [IQR] 18.0-28.8 mm) and 0.18 cm3 (IQR 0.13-0.28 cm3), respectively. In 55% of patients, endocrine function normalized or improved in their affected axes by median last clinical follow-up of 24.4 months (IQR 3.2-51.2 months). Older age, male sex, and larger tumor size were associated with likelihood of endocrine recovery. Median time to recovery of any axis was 12.2 months (IQR 2.5-23.9 months); hypothyroidism was the slowest axis to recover. Although the gland significantly reexpanded from preoperatively (0.18 cm3, IQR 0.13-0.28 cm3) to postoperatively (0.33 cm3, IQR 0.23-0.48 cm3; p < 0.001), there was no consistent association with improved endocrine function.CONCLUSIONSRecovery of endocrine function can occur several months and even years after surgery, with more than 50% of patients showing improved or normalized function. Tumor size, and not gland volume, was associated with preserved or recovered endocrine function.

6.
Neurosurgery ; 83(6): 1249-1259, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-29481613

RESUMO

BACKGROUND: Despite improved perioperative management, the rate of postoperative morbidity and mortality after brain tumor resection remains considerably high. OBJECTIVE: To assess the rates, causes, timing, and predictors of major complication, extended length of stay (>10 d), reoperation, readmission, and death within 30 d after craniotomy for primary malignant brain tumors. METHODS: Patients were extracted from the National Surgical Quality Improvement Program registry (2005-2015) and analyzed using multivariable logistic regression. RESULTS: A total of 7376 patients were identified, of which 948 (12.9%) experienced a major complication. The most common major complications were reoperation (5.1%), venous thromboembolism (3.5%), and death (2.6%). Furthermore, 15.6% stayed longer than 10 d, and 11.5% were readmitted within 30 d after surgery. The most common reasons for reoperation and readmission were intracranial hemorrhage (18.5%) and wound-related complications (11.9%), respectively. Multivariable analysis identified older age, higher body mass index, higher American Society of Anesthesiologists (ASA) classification, dependent functional status, elevated preoperative white blood cell count (white blood cell count [WBC], >12 000 cells/mm3), and longer operative time as predictors of major complication (all P < .001). Higher ASA classification, dependent functional status, elevated WBC, and ventilator dependence were predictors of extended length of stay (all P < .001). Higher ASA classification and elevated WBC were predictors of reoperation (both P < .001). Higher ASA classification and dependent functional status were predictors of readmission (both P < .001). Older age, higher ASA classification, and dependent functional status were predictors of death (all P < .001). CONCLUSION: This study provides a descriptive analysis and identifies predictors for short-term complications, including death, after craniotomy for primary malignant brain tumors.


Assuntos
Neoplasias Encefálicas/cirurgia , Craniotomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Idoso , Neoplasias Encefálicas/mortalidade , Craniotomia/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Melhoria de Qualidade , Resultado do Tratamento
7.
World Neurosurg ; 109: e676-e683, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29061463

RESUMO

BACKGROUND: Chordoma that occurs primarily in the sella turcica is rare and presents unique treatment challenges. OBJECTIVE: The purpose of this study was to determine common features, treatment approaches, and survival characteristics of intrasellar chordoma. METHODS: Institutional databases, the SEER (Surveillance Epidemiology and End Results) database, and PubMed/EMBASE were queried for chordoma with a primarily intrasellar component. The SEER database was also queried for adult skull base chordoma. Patient-level data were extracted where available. Kaplan-Meier survival analyses were conducted. RESULTS: Among 80 cases, the mean age at presentation was 55.6 (standard deviation, 15.9), with a female predominance (1.16:1.00). Patients experienced symptoms for a mean duration of 19.0 months, including cranial nerve deficits, hypopituitarism, and hyperprolactinemia. Among patients receiving treatment, 77.5% underwent surgery. In addition, less than half of the patients (n = 34, 47.3%) received adjuvant radiation therapy. The 5-year overall survival (OS) of intrasellar chordoma was 60.0% (standard error [SE], 6.9). Patients aged 40 years and younger had a 5-year OS of 80.8% (SE, 12.2), compared with patients older than 40 years, who had an OS of 55.4% (SE, 7.7) (Mantel-Cox, P = 0.044). Males experienced a lower 5-year OS (44.0; SE, 9.7) than did females (76.8; SE, 8.5), (Mantel-Cox, P = 0.003). Median OS was greater in patients with skull base chordoma than in patients with intrasellar chordoma (Mantel-Cox, P = 0.046). CONCLUSIONS: Intrasellar chordoma presents frequently with visual disturbances and hyperprolactinemia and has a slightly higher incidence in females. Young age predicts a better prognosis. Intrasellar chordoma has a lower overall survival than has skull base chordoma.


Assuntos
Cordoma/diagnóstico , Programa de SEER/tendências , Neoplasias da Base do Crânio/diagnóstico , Estatística como Assunto/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Cordoma/mortalidade , Cordoma/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias da Base do Crânio/mortalidade , Neoplasias da Base do Crânio/cirurgia , Estatística como Assunto/métodos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
8.
J Neurooncol ; 136(1): 135-145, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29039075

RESUMO

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), frequently complicates the postoperative course of primary malignant brain tumor patients. Thromboprophylactic anticoagulation is commonly used to prevent VTE at the risk of intracranial hemorrhage (ICH). We extracted all patients who underwent craniotomy for a primary malignant brain tumor from the National Surgical Quality Improvement Program (NSQIP) registry (2005-2015) to perform a time-to-event analysis and identify relevant predictors of DVT, PE, and ICH within 30 days after surgery. Among the 7376 identified patients, the complication rates were 2.6, 1.5, and 1.3% for DVT, PE, and ICH, respectively. VTE was the second-most common major complication and third-most common reason for readmission. ICH was the most common reason for reoperation. The increased risk of VTE extends beyond the period of hospitalization, especially for PE, whereas ICH occurred predominantly within the first days after surgery. Older age and higher BMI were overall predictors of VTE. Dependent functional status and longer operative times were predictive for VTE during hospitalization, but not for post-discharge events. Admission two or more days before surgery was predictive for DVT, but not for PE. Preoperative steroid usage and male gender were predictive for post-discharge DVT and PE, respectively. ICH was associated with various comorbidities and longer operative times. This multicenter study demonstrates distinct critical time periods for the development of thrombotic and hemorrhagic events after craniotomy. Furthermore, the VTE risk profile depends on the type of VTE (DVT vs. PE) and clinical setting (hospitalized vs. post-discharge patients).


Assuntos
Neoplasias Encefálicas/cirurgia , Craniotomia/efeitos adversos , Hemorragias Intracranianas/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Tromboembolia Venosa/epidemiologia , Feminino , Humanos , Hemorragias Intracranianas/etiologia , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Fatores de Tempo , Tromboembolia Venosa/etiologia
9.
Acta Neurochir (Wien) ; 159(11): 2209-2216, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28948361

RESUMO

BACKGROUND: Rarely, granular cell tumor (GCT) occurs in the sellar region. The natural history of this clinical entity is not well known. This study sought to determine the clinical features and long-term outcome of GCT of the sellar region. METHODS: Institutional databases, the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and PubMed/EMBASE were searched for GCT of the sellar region. Patient-level data were extracted where available, including age, sex, symptoms, tumor size and location, presumed diagnosis, surgical approach and result, subtotal resection (STR) and gross-total resection (GTR), use of radiation, and outcome. The primary endpoints of recurrence and survival were determined. RESULTS: A total of 141 cases were analyzed. The mean age at diagnosis was 48.9 (SD 15.3) with a female predominance (sex ratio 1.49:1). Almost all patients experienced either or both neurological and endocrine symptoms. The most common pre-operative diagnosis was pituitary adenoma. Approximately 60% of patients were treated with surgery, 57.7% with a craniotomy, and 39.7% with a transsphenoidal approach. The 5-year overall survival (OS) was 84.7% (standard error, SE 4.2). Patients with tumors less than 2.5 cm experienced a greater 5-year OS (100.0%) than patients with tumors 2.5 cm or larger (74.0%, SE: 11.7), (Mantel-Cox, p = 0.024). GTR resulted in a greater 5-year OS (95.7%, SE 4.3) than STR (88.8%, SE 5.5) and no surgery or biopsy alone (75.0%, SE 15.3) (Mantel-Cox, p = 0.016). The use of radiation therapy did not improve OS. The 5-year progression-free survival rate was 80.8% (SE 9.2). CONCLUSIONS: Granular cell tumor of the sellar region is a relatively benign neoplasm with neurological and endocrine clinical manifestations. Surgical resection is appropriate for management. Tumor size and extent of resection influence overall survival.


Assuntos
Neoplasias Encefálicas/cirurgia , Tumor de Células Granulares/cirurgia , Sela Túrcica , Adenoma/diagnóstico , Adolescente , Adulto , Distribuição por Idade , Idoso , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/epidemiologia , Neoplasias Encefálicas/patologia , Craniotomia , Bases de Dados Factuais , Diagnóstico Diferencial , Intervalo Livre de Doença , Feminino , Tumor de Células Granulares/diagnóstico , Tumor de Células Granulares/epidemiologia , Tumor de Células Granulares/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Neoplasias Hipofisárias/diagnóstico , Prognóstico , Estudos Retrospectivos , Distribuição por Sexo , Resultado do Tratamento , Carga Tumoral , Adulto Jovem
10.
World Neurosurg ; 107: 534-541, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28823671

RESUMO

BACKGROUND: Although the World Health Organization classifies papillary glioneuronal tumor (PGNT) as a grade I tumor, several malignant cases have been reported. In this study, we examined the clinical and prognostic characteristics of PGNT. METHODS: PubMed, Embase, and institutional databases were queried for patient-level reports of PGNT, resulting in identification of 138 cases. Descriptive and Kaplan-Meier survival analyses were conducted. The threshold of significance was 0.05. RESULTS: The mean age at presentation was 26.9 ± 16.3 years, and the incidence was higher in males (1.42:1). Tumors with a high Ki-67 index (≥5) were more likely to exhibit perilesional edema and ring enhancement on magnetic resonance imaging, trending toward significance (P = 0.114 and 0.113, respectively). Compared with tumors with a low Ki-67 index (<5), those with a high Ki-67 index were more likely to be treated with subtotal resection (STR) than with gross total resection (GTR) (Kruskal-Wallis test, P = 0.006) and with radiation therapy (χ2 test, P = 0.010). At 5 years post-treatment, PGNT had a mean progression-free survival (PFS) of 85.9 ± 3.9%. Males had a better 5-year PFS than females (94.0 ± 3.4% vs. 74.8 ± 7.8%; Mantel-Cox test, P = 0.002). Two-year PFS was higher after GTR than after STR (91.9 ± 3.6% vs. 46.7 ± 21.4%; Mantel-Cox test, P < 0.001). A low Ki-67 index was associated with a higher 5-year PFS compared with a high Ki-67 index (94.8 ± 3.6% vs. 55.6 ± 12.9%; Mantel-Cox test, P < 0.001). CONCLUSIONS: PGNT is a benign tumor of young adults, but can present atypically as high grade. Male sex, low cellular proliferation, and maximal surgical resection are positive prognostic indicators for PGNT.


Assuntos
Neoplasias Encefálicas/cirurgia , Carcinoma Papilar/cirurgia , Doenças Raras/cirurgia , Adulto , Biomarcadores Tumorais/metabolismo , Neoplasias Encefálicas/mortalidade , Neoplasias Encefálicas/patologia , Carcinoma Papilar/mortalidade , Carcinoma Papilar/patologia , Proliferação de Células , Intervalo Livre de Doença , Feminino , Humanos , Antígeno Ki-67/metabolismo , Masculino , Prognóstico , Doenças Raras/mortalidade , Doenças Raras/patologia , Resultado do Tratamento
11.
J Clin Neurosci ; 45: 24-32, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28802796

RESUMO

BACKGROUND: Perioperative antibiotic prophylaxis against gram positive and gram negative infections is considered standard of care in the perioperative management of patients undergoing cranial surgery. The antibiotic regimen which best reduces the risk of surgical site infections (SSIs) remains controversial. OBJECTIVES: A systematic literature review and meta-analysis were conducted to examine the effect of various prophylactic antibiotics on infection incidence among patients undergoing cranial surgeries. METHODS: A comprehensive search was conducted on Pubmed, EMBASE and Cochrane databases through October 2014 for studies that evaluated the efficacy of antibiotic prophylaxis among patients undergoing cranial surgeries. Pooled effect estimates using both fixed- and random-effect models were calculated. RESULTS: Eight articles were included in the meta-analysis, with a combined total of 1655 cranial procedures. Among these, 74 cases of SSIs were reported after patients received a single antibiotic or a combination of 2 or more antibiotics (pooled incidence of SSIs=6.00%; 95% CI=4.80%, 7.50%; fixed-effects model; I2=73.7%; P-heterogeneity<0.01). Incidence of SSI was 1.00% (95% CI=0.40%, 2.60%) for non-MRSA gram-positive bacterial infections; 2.70% (95% CI=0.90%, 8.00%) for gram-negative bacterial infections; 6.00% (95% CI=4.50%, 7.80%) for gram negative, and non-MRSA gram-positive bacterial infections; and 11.3% (95% CI=7.20%, 17.4%) for gram negative and MRSA gram-positive bacterial infections. Subgroup analysis revealed an effect modification by drug class (P=0.05) and infection type (P-interaction=0.01). More specifically, lincosamides (2.70%; n=1 group), glycopeptides (2.80%; n=1), third generation cephalosporins (5.30%; n=2), antibiotics combination (4.90%; n=4), and penicillin-family antibiotics (5.90%, n=1) offered better coverage against infections than first generation cephalosporins (22.0%; n=2). A meta-regression analysis on study length was not significant (P=0.13). Random-effect models were not materially different form fixed-effects. No evidence of publication bias was found. CONCLUSION: Lincosamides, glycopeptides, third generation cephalosporins, other combinations of prophylactic antibiotics, or penicillin-family antibiotics alone offer better coverage against SSIs than first generation cephalosporin among cranial surgery patients.


Assuntos
Antibioticoprofilaxia/métodos , Craniotomia/efeitos adversos , Infecções por Bactérias Gram-Negativas/prevenção & controle , Infecções por Bactérias Gram-Positivas/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/normas , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Infecções por Bactérias Gram-Negativas/epidemiologia , Infecções por Bactérias Gram-Negativas/etiologia , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções por Bactérias Gram-Positivas/epidemiologia , Infecções por Bactérias Gram-Positivas/etiologia , Humanos , Penicilinas/administração & dosagem , Penicilinas/uso terapêutico , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/epidemiologia
12.
J Clin Neurosci ; 42: 1-6, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28215426

RESUMO

BACKGROUND: Cognitive impairment following transsphenoidal surgery (TSS) among patients with pituitary tumors has been intermittently reported and is not well established. We performed a systematic review to summarize the impact of TSS on cognitive function. METHODS: We conducted a systematic search of the literature using the PubMed, Cochrane, and Embase databases through October 2014. Studies were selected if they reported cognitive status after surgery and included at least 10 adult patients with pituitary tumors undergoing either endoscopic or microscopic TSS. RESULTS: After removing 69 duplicates, 758 articles were identified, of which 24 were selected for full text review after screening titles and abstracts. After reviewing full texts, nine studies with a combined total of 682 patients were included in the final analysis. Eight studies were cross-sectional and one was longitudinal. These studies used a wide variety of neurocognitive tests to assess memory, attention and executive function post-operatively. Of the eight studies, six reported impairments in verbal and non-verbal memory post-operatively, while others found no association related to memory, and some reported an improvement in episodic, verbal, or logical memory. While four studies found an impaired association between TSS and attention or executive function, another four studies did not. CONCLUSION: The current literature on cognitive impairments after TSS is limited and inconsistent. This review demonstrates that patients undergoing TSS may experience a variety of effects on executive function and memory post-operatively, but changes in verbal memory are most common.


Assuntos
Adenoma/cirurgia , Transtornos Cognitivos/etiologia , Cognição , Procedimentos Neurocirúrgicos/efeitos adversos , Neoplasias Hipofisárias/cirurgia , Complicações Pós-Operatórias/epidemiologia , Atenção , Transtornos Cognitivos/epidemiologia , Humanos , Memória , Procedimentos Neurocirúrgicos/métodos , Comportamento Verbal
13.
Semin Thromb Hemost ; 42(8): 877-883, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27574964

RESUMO

Venous thromboembolism (VTE), incorporating both deep vein thrombosis and pulmonary embolism, is a common, morbid, and potentially fatal condition. Patients undergoing surgery are at increased risk of VTE due to many perioperative factors, and patients undergoing surgery for high-grade glioma (HGG) have been found to be at an even higher risk than general surgical patients. Chemical prophylaxis of VTE during the postneurosurgical period remains one of the major dilemmas in modern neurosurgical practice due to a potential increased risk of devastating intracranial hemorrhage in the setting of anticoagulation. In this review, we aim to summarize the prevalence of VTE in patients with HGG and discuss relevant risk factors for the development of VTE after surgery for this malignancy. We also review options for VTE prophylaxis in the postoperative period and discuss appropriate management of these complex patients.


Assuntos
Neoplasias Encefálicas/complicações , Glioma/complicações , Tromboembolia Venosa/etiologia , Humanos , Gradação de Tumores , Fatores de Risco , Tromboembolia Venosa/epidemiologia
14.
AIDS Res Hum Retroviruses ; 31(11): 1139-52, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26204200

RESUMO

Bacterial vaginosis (BV) has been linked to an increased risk of human immunodeficiency virus (HIV) acquisition and transmission in observational studies, but the underlying biological mechanisms are unknown. We measured biomarkers of subclinical vaginal inflammation, endogenous antimicrobial activity, and vaginal flora in women with BV and repeated sampling 1 week and 1 month after completion of metronidazole therapy. We also compared this cohort of women with BV to a healthy control cohort without BV. A longitudinal, open label study of 33 women with a Nugent score of 4 or higher was conducted. All women had genital swabs, cervicovaginal lavage (CVL) fluid, and cervicovaginal biopsies obtained at enrollment and received 7 days of metronidazole treatment. Repeat sampling was performed approximately 1 week and 1 month after completion of therapy. Participant's baseline samples were compared to a healthy, racially matched control group (n=13) without BV. The CVL from women with resolved BV (Nugent 0-3) had significantly higher anti-HIV activity, secretory leukocyte protease inhibitor (SLPI), and growth-related oncogene alpha (GRO-α) levels and their ectocervical tissues had significantly more CD8 cells in the epithelium. Women with persistent BV after treatment had significantly higher levels of interleukin-1ß, tumor necrosis factor alpha (TNF-α), and intercellular adhesion molecule 1 (ICAM-1) in the CVL. At study entry, participants had significantly greater numbers of CCR5(+) immune cells and a higher CD4/CD8 ratio in ectocervical tissues prior to metronidazole treatment, compared to a racially matched cohort of women with a Nugent score of 0-3. These data indicate that BV is associated with changes in select soluble immune mediators, an increase in HIV target cells, and a reduction in endogenous antimicrobial activity, which may contribute to the increased risk of HIV acquisition.


Assuntos
Biomarcadores/análise , Imunidade nas Mucosas , Inflamação/patologia , Infecções do Sistema Genital/diagnóstico , Infecções do Sistema Genital/patologia , Vaginose Bacteriana/diagnóstico , Adulto , Anti-Infecciosos/administração & dosagem , Infecções Assintomáticas , Biópsia , Colo do Útero/microbiologia , Feminino , Humanos , Estudos Longitudinais , Metronidazol/administração & dosagem , Infecções do Sistema Genital/tratamento farmacológico , Vagina/microbiologia , Ducha Vaginal , Vaginose Bacteriana/tratamento farmacológico
15.
Am J Reprod Immunol ; 73(5): 437-44, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25521546

RESUMO

PROBLEM: Severe preeclampsia has been independently linked to complement dysregulation and angiogenic imbalance; however, the relationship between complement and angiogenic factors in human pregnancy is unclear. METHOD OF STUDY: Utilizing existing biomarkers, our study sought to better understand this relationship in active disease. We performed a case-control study, enrolling 25 cases with severe preeclampsia, 25 controls with chronic hypertension, and 25 healthy controls without hypertension. Levels of complement components (C3a, C5a, and C5b-9) and angiogenic markers [basic fibroblast growth factor (bFGF), placental growth factor (PlGF), vascular endothelial growth factor (VEGF), and soluble fms-like tyrosine kinase-1 (sFlt-1)] were measured simultaneously. RESULTS: Compared to both hypertensive and non-hypertensive controls, severe preeclampsia was associated with increased plasma sFlt-1, decreased plasma VEGF and PlGF, decreased urinary PlGF, and increased urinary C5b-9. Urinary marker C5b-9 correlated strongly with the anti-angiogenic condition. In subjects with detectable urinary excretion of C5b-9, median plasma levels of sFlt-1 were significantly greater (32,029 versus 4556 pg/mL, P < 0.0001) and levels of PlGF (15.6 versus 226 pg/mL, P < 0.0001) and VEGF (119 versus 153 pg/mL, P = 0.001) were significantly lower. CONCLUSION: More so than plasma complement markers, urinary C5b-9 may a useful measure to link complement dysregulation with angiogenic imbalance in severe preeclampsia.


Assuntos
Complexo de Ataque à Membrana do Sistema Complemento/urina , Pré-Eclâmpsia/urina , Adulto , Biomarcadores/urina , Estudos de Casos e Controles , Feminino , Fator 2 de Crescimento de Fibroblastos/urina , Seguimentos , Humanos , Fator de Crescimento Placentário , Gravidez , Proteínas da Gravidez/urina , Fator A de Crescimento do Endotélio Vascular/urina , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/urina
16.
Hypertension ; 64(4): 833-8, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24958504

RESUMO

Kidney injury with proteinuria is a characteristic feature of preeclampsia, yet the nature of injury in specific regions of the nephron is incompletely understood. Our study aimed to use existing urinary biomarkers to describe the pattern of kidney injury and proteinuria in pregnancies affected by severe preeclampsia. We performed a case-control study of pregnant women from Brigham and Women's Hospital from 2012 to 2013. We matched cases of severe preeclampsia (n=25) 1:1 by parity and gestational age to 2 control groups with and without chronic hypertension. Urinary levels of kidney injury molecule-1 and complement components (C3a, C5a, and C5b-9) were measured by enzyme-linked immunosorbent assay, and other markers (albumin, ß2 microglobulin, cystatin C, epithelial growth factor, neutrophil gelatinase-associated lipocalin, osteopontin, and uromodulin) were measured simultaneously with a multiplex electrochemiluminescence assay. Median values between groups were compared with the Wilcoxon signed-rank test and correlations with Spearman correlation coefficient. Analysis of urinary markers revealed higher excretion of albumin and kidney injury molecule-1 and lower excretion of neutrophil gelatinase-associated lipocalin and epithelial growth factor in severe preeclampsia compared with chronic hypertension and healthy controls. Among subjects with severe preeclampsia, urinary excretion of complement activation products correlated most closely with kidney injury molecule-1, a specific marker of proximal tubule injury (C5a: r=0.60; P=0.001; and C5b-9: r=0.75; P<0.0001). Taken together, we describe a pattern of kidney injury in severe preeclampsia that is characterized by glomerular impairment and complement-mediated inflammation and injury, possibly localized to the proximal tubule in association with kidney injury molecule-1.


Assuntos
Ativação do Complemento/imunologia , Túbulos Renais Proximais/imunologia , Glicoproteínas de Membrana/imunologia , Pré-Eclâmpsia/imunologia , Receptores Virais/imunologia , Proteínas da Fase Aguda/imunologia , Proteínas da Fase Aguda/urina , Adulto , Albuminúria/imunologia , Albuminúria/urina , Biomarcadores/urina , Estudos de Casos e Controles , Complemento C3a/imunologia , Complemento C3a/urina , Complemento C5a/imunologia , Complemento C5a/urina , Complexo de Ataque à Membrana do Sistema Complemento/imunologia , Complexo de Ataque à Membrana do Sistema Complemento/urina , Fator de Crescimento Epidérmico/imunologia , Fator de Crescimento Epidérmico/urina , Feminino , Receptor Celular 1 do Vírus da Hepatite A , Humanos , Túbulos Renais Proximais/lesões , Lipocalina-2 , Lipocalinas/imunologia , Lipocalinas/urina , Glicoproteínas de Membrana/urina , Osteopontina/imunologia , Osteopontina/urina , Pré-Eclâmpsia/patologia , Pré-Eclâmpsia/urina , Gravidez , Proteínas Proto-Oncogênicas/imunologia , Proteínas Proto-Oncogênicas/urina , Índice de Gravidade de Doença , Uromodulina/imunologia , Uromodulina/urina , Microglobulina beta-2/imunologia , Microglobulina beta-2/urina
17.
J Pediatr ; 164(6): 1486-8, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24636854

RESUMO

Necrotizing enterocolitis, characterized by sudden onset and rapid progression, remains the most significant gastrointestinal disorder among premature infants. In seeking a predictive biomarker, we found intestinal fatty acid binding protein, an indicator of enterocyte damage, was substantially increased within three and seven days before the diagnosis of necrotizing enterocolitis.


Assuntos
Enterocolite Necrosante/fisiopatologia , Enterocolite Necrosante/urina , Proteínas de Ligação a Ácido Graxo/urina , Recém-Nascido Prematuro , Biomarcadores/urina , Peso ao Nascer , Estudos de Coortes , Progressão da Doença , Feminino , Idade Gestacional , Hospitais Pediátricos , Humanos , Recém-Nascido , Masculino , Razão de Chances , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas
18.
Hypertension ; 62(6): 1040-5, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24060886

RESUMO

The complement cascade is activated in normal pregnancy, and excessive complement activation propagates the systemic inflammatory response in severe preeclampsia. Consequently, biomarkers of complement dysregulation may be useful for prediction or treatment of disease. Because renal damage with proteinuria is a characteristic pathological feature of preeclampsia, we hypothesized that complement markers in urine, rather than plasma, could better reflect complement dysregulation in disease. To investigate this, we performed a case-control study of pregnant women, enrolling 25 cases with severe preeclampsia, 25 controls with chronic hypertension, and 25 healthy controls without hypertension matched by gestational age and parity. Subjects were recruited from the Brigham and Women's Hospital from March 2012 to March 2013. Urine and blood samples were collected on the day of enrollment, with complement activation (C3a, C5a, and C5b-9) measured by ELISA. Severe preeclampsia was associated with marked elevations in urinary C5b-9 (median [interquartile range], 4.3 [1.2-15.1] ng/mL) relative to subjects with chronic hypertension (0 [0-0]) and healthy controls (0 [0-0]; P<0.0001). Urinary excretion of C5b-9 was detected in 96% of cases with severe preeclampsia, 12% of controls with chronic hypertension, and 8% of healthy controls. Cases were also notable for significantly greater urinary excretion of C3a and C5a. Plasma levels of C5a and C5b-9, but not C3a, were increased in the cases with severe preeclampsia compared with healthy controls; however, they did not distinguish preeclampsia from chronic hypertension, supporting our hypothesis that complement markers in urine, rather than plasma, better reflect complement dysregulation. Complement inhibition is an intriguing treatment option for patients with severe preeclampsia.


Assuntos
Ativação do Complemento , Complexo de Ataque à Membrana do Sistema Complemento/urina , Pré-Eclâmpsia/urina , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Hipertensão/imunologia , Hipertensão/urina , Pré-Eclâmpsia/imunologia , Gravidez , Proteinúria/imunologia , Proteinúria/urina
19.
Sex Transm Infect ; 89(6): 460-6, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23903808

RESUMO

OBJECTIVES: Complex interactions of vaginal microorganisms with the genital tract epithelium shape mucosal innate immunity, which holds the key to sexual and reproductive health. Bacterial vaginosis (BV), a microbiome-disturbance syndrome prevalent in reproductive-age women, occurs commonly in concert with trichomoniasis, and both are associated with increased risk of adverse reproductive outcomes and viral infections, largely attributable to inflammation. To investigate the causative relationships among inflammation, BV and trichomoniasis, we established a model of human cervicovaginal epithelial cells colonised by vaginal Lactobacillus isolates, dominant in healthy women, and common BV species (Atopobium vaginae, Gardnerella vaginalis and Prevotella bivia). METHODS: Colonised epithelia were infected with Trichomonas vaginalis (TV) or exposed to purified TV virulence factors (membrane lipophosphoglycan (LPG), its ceramide-phosphoinositol-glycan core (CPI-GC) or the endosymbiont Trichomonas vaginalis virus (TVV)), followed by assessment of bacterial colony-forming units, the mucosal anti-inflammatory microbicide secretory leucocyte protease inhibitor (SLPI), and chemokines that drive pro-inflammatory, antigen-presenting and T cells. RESULTS: TV reduced colonisation by Lactobacillus but not by BV species, which were found inside epithelial cells. TV increased interleukin (IL)-8 and suppressed SLPI, likely via LPG/CPI-GC, and upregulated IL-8 and RANTES, likely via TVV as suggested by use of purified pathogenic determinants. BV species A vaginae and G vaginalis induced IL-8 and RANTES, and also amplified the pro-inflammatory responses to both LPG/CPI-GC and TVV, whereas P bivia suppressed the TV/TVV-induced chemokines. CONCLUSIONS: These molecular host-parasite-endosymbiont-bacteria interactions explain epidemiological associations and suggest a revised paradigm for restoring vaginal immunity and preventing BV/TV-attributable inflammatory sequelae in women.


Assuntos
Bactérias/imunologia , Células Epiteliais/imunologia , Imunidade Inata , Interações Microbianas , Trichomonas vaginalis/imunologia , Bactérias/patogenicidade , Células Cultivadas , Quimiocinas/metabolismo , Contagem de Colônia Microbiana , Células Epiteliais/microbiologia , Células Epiteliais/parasitologia , Feminino , Humanos , Inibidor Secretado de Peptidases Leucocitárias/metabolismo , Trichomonas vaginalis/patogenicidade
20.
J Infect Dis ; 207(9): 1462-70, 2013 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-23355743

RESUMO

BACKGROUND: Secretory leukocyte protease inhibitor (SLPI) is responsible for regulating inflammatory damage to and innate and adaptive immune responses in the vaginal mucosa. Depressed cervicovaginal SLPI levels have been correlated with both Trichomonas vaginalis infection and poor reproductive health outcomes. METHODS: We measured levels of SLPI in 215 vaginal specimens collected from adolescent and young adult females aged 14-22 years. Log-transformed SLPI values were compared by analysis of variance or by an unpaired t test before and after adjustment for confounding effects through the propensity score method. RESULTS: Females receiving hormonal contraceptives and those with an abnormal vaginal pH had lower SLPI levels as compared to their peers. After propensity score adjustment for race, behavioral factors, hormonal use, and other sexually transmitted infections (STIs), SLPI levels were lower in females with a positive T. vaginalis antigen test result, a vaginal pH >4.5, vaginal leukocytosis, and recurrent (vs initial) T. vaginalis infection, with the lowest levels observed in those with the highest T. vaginalis loads. CONCLUSIONS: The SLPI level was reduced by >50% in a T. vaginalis load-dependent manner. Future research should consider whether identifying and treating females with low levels of T. vaginalis infection (before they become wet mount positive) would prevent the loss of SLPI and impaired vaginal immunity. The SLPI level could be used as a vaginal-health marker to evaluate interventions and vaginal products.


Assuntos
Biomarcadores/análise , Infecções do Sistema Genital/imunologia , Infecções do Sistema Genital/parasitologia , Inibidor Secretado de Peptidases Leucocitárias/análise , Trichomonas vaginalis/patogenicidade , Vagina/imunologia , Vagina/parasitologia , Adolescente , Feminino , Humanos , Carga Parasitária , Inibidor Secretado de Peptidases Leucocitárias/imunologia , Trichomonas vaginalis/imunologia , Adulto Jovem
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