bluuebunny/crossref_metadata_2025 huggingface dataset:
From Theory to Practice: Preventing Pain After Cardiac Surgery
Authors: Reimer-Kent Jocelyn
Published: November 2019

A pain management guideline was developed at the Royal Columbian Hospital, New Westminster, British Columbia, to prevent pain after cardiac surgery. The guideline was based on a wellness model and was predicated on the World Health Organization’s analgesic ladder. Patients are given nonopioids around the clock and throughout the postoperative stay and are given an opioid to prevent procedural pain and treat breakthrough pain. In an evaluation of the guideline, records from 133 cardiac surgery patients were retrospectively reviewed. The type and dose of analgesics administered for the first 6 days after surgery, the effectiveness of the pain management plan, the occurrence of adverse effects, time to extubation, and postoperative lengths of stay were determined. Ninety-five percent of patients had effective pain relief. Almost all patients received acetaminophen around the clock. A total of 89% received indomethacin. All patients received opioids intermittently. Doses of opioids were converted to morphine oral equivalents, which peaked on day 1 after surgery (38 equivalents) and decreased sharply by day 2 (<10 equivalents). Median postoperative length of stay was 5 days for patients who had bypass surgery and 6 days for patients who had valve surgery. This proactive, low-tech, low-risk, well-tolerated pain management approach is cost-effective, simple, and feasible to use. The findings support use of this approach in managing pain after cardiac surgery.
Naturalistic Decision Making: A Model to Overcome Methodological Challenges in the Study of Critical Care Nurses’ Decision Making About Patients’ Hemodynamic Status
Authors: Currey Judy , Botti Mari
Published: November 2019

The quality of critical care nurses’ decision making about patients’ hemodynamic status in the immediate period after cardiac surgery is important for the patients’ well-being and, at times, survival. The way nurses respond to hemodynamic cues varies according to the nurses’ skills, experiences, and knowledge. Variability in decisions is also associated with the inherent complexity of hemodynamic monitoring. Previous methodological approaches to the study of hemodynamic assessment and treatment decisions have ignored the important interplay between nurses, the task, and the environment in which these decisions are made. The advantages of naturalistic decision making as a framework for studying the manner in which nurses make decisions are presented.
Physicians’ Estimates of Cardiac Index and Intravascular Volume Based on Clinical Assessment Versus Transesophageal Doppler Measurements Obtained by Critical Care Nurses
Authors: Iregui Manuel G. , Prentice Donna , Sherman Glenda , Schallom Lynn , Sona Carrie , Kollef Marin H.
Published: November 2019

• Objectives To compare physicians’ estimates of cardiac index and intravascular volume with transesophageal Doppler measurements obtained by critical care nurses, to assess the overall safety of transesophageal Doppler imaging by critical care nurses, and to compare hemodynamic measurements obtained via transesophageal Doppler imaging with those obtained via pulmonary artery catheterization.

• Methods Data were collected prospectively on 106 patients receiving mechanical ventilation. Physicians estimated cardiac index and intravascular volume status by using bedside clinical assessment; critical care nurses, by using transesophageal Doppler imaging. In 24 patients, Doppler measurements were obtained within 6 hours of placement of a pulmonary artery catheter and recording of cardiac output and pulmonary artery occlusion pressure.

• Results With Doppler measurements as the reference, physicians correctly estimated cardiac index in 46 (43.8%) of 105 patients, underestimated it in 24 (22.9%), and overestimated it in 35 (33.3%). They correctly estimated volume status in 31 patients (29.5%), underestimated it in 16 (15.2%), and overestimated it in 58 (55.2%). Doppler measurements of cardiac output correlated with those obtained via pulmonary artery catheterization (r = 0.778; P < .001). Two patients had minor complications: dislodgement of a nasogastric tube and inability to obtain a Doppler signal.

• Conclusion Physicians’ assessment of cardiac index and intravascular volume in patients receiving mechanical ventilation is correct less than half of the time. Transesophageal Doppler imaging by critical care nurses appears to be a safe method for measuring cardiac index and estimating intravascular volume. Measurements obtained via Doppler imaging correlate well with those obtained via pulmonary artery catheterization.
Oral Health and Care in the Intensive Care Unit: State of the Science
Authors: Munro Cindy L. , Grap Mary Jo
Published: November 2019

Oral health is influenced by oral microbial flora, which are concentrated in dental plaque. Dental plaque provides a microhabitat for organisms and an opportunity for adherence of the organisms to either the tooth surface or other microorganisms. In critically ill patients, potential pathogens can be cultured from the oral cavity. These microorganisms in the mouth can translocate and colonize the lung, resulting in ventilator-associated pneumonia. The importance of oral care in the intensive care unit has been noted in the literature, but little research is available on mechanical or pharmacological approaches to reducing oral microbial flora via oral care in critically ill adults. Most research in oral care has been directed toward patients’ comfort; the microbiological and physiological effects of tooth brushing in the intensive care unit have not been reported. Although 2 studies indicated reductions in rates of ventilator-associated pneumonia in cardiac surgery patients who received chlorhexidine before intubation and postoperatively, the effects of chlorhexidine in reducing ventilator-associated pneumonia in other populations of critically ill patients or its effect when treatment with the agent initiated after intubation have not been reported. In addition, no evaluation of the effectiveness of pharmacological and mechanical interventions relative to each other or in combination has been published. Additional studies are needed to develop and test best practices for oral care in critically ill patients.
Effects of Acuity-Adaptable Rooms on Flow of Patients and Delivery of Care
Authors: Hendrich Ann L. , Fay Joy , Sorrells Amy K.
Published: November 2019

• Background Delayed transfers of patients between nursing units and lack of available beds are significant problems that increase costs and decrease quality of care and satisfaction among patients and staff.

• Objective To test whether use of acuity-adaptable rooms helps solve problems with transfers of patients, satisfaction levels, and medical errors.

• Methods A pre-post method was used to compare the effects of environmental design on various clinical and financial measures. Twelve outcome-based questions were formulated as the basis for inquiry. Two years of baseline data were collected before the unit moved and were compared with 3 years of data collected after the move.

• Results Significant improvements in quality and operational cost occurred after the move, including a large reduction in clinician handoffs and transfers; reductions in medication error and patient fall indexes; improvements in predictive indicators of patients’ satisfaction; decrease in budgeted nursing hours per patient day and increased available nursing time for direct care without added cost; increase in patient days per bed, with a smaller bed base (number of beds per patient days). Some staff turnover occurred during the first year; turnover stabilized thereafter.

• Conclusions Data in 5 key areas (flow of patients and hospital capacity, patients’ dissatisfaction, sentinel events, mean length of stay, and allocation of nursing productivity) appear to be sufficient to test the business case for future investment in partial or complete replication of this model with appropriate populations of patients.
Assessment of Anxiety in Intensive Care Patients By Using the Faces Anxiety Scale
Authors: McKinley Sharon , Stein-Parbury Jane , Chehelnabi Afsaneh , Lovas Judy
Published: November 2019

• Background Anxiety is difficult to detect in patients receiving mechanical ventilation because clinical signs are confounded and patients often cannot respond to validated anxiety measures. Most patients can respond to the single-item Faces Anxiety Scale.

• Objectives To assess the validity of the Faces Anxiety Scale, the frequency and severity of state anxiety, and correlates of anxiety in intensive care patients.

• Methods A research assistant made a single clinical judgment of anxiety in the range of 1 to 10 on the basis of patients’ nonverbal responses (ie, nods) to 9 questions about mood and their physical and behavioral signs. Patients then responded to the Faces Anxiety Scale. Demographic, clinical, and pharmacological data were obtained from the patients’ charts.

• Results Mean age of the 106 patients was 61 years; 62% were men. Admission diagnoses were cardiovascular in 26% of patients, respiratory in 26%, trauma in 18%, neurological in 12%, gastrointestinal in 12%, and other in 6%. At the time of anxiety assessment, 89% were receiving mechanical ventilation. The correlation between patients’ self-reports of anxiety on the Anxiety Faces Scale and the research assistant’s assessments was 0.64 (P < .001). Some anxiety was reported by 85% of patients (mean level 2.9; SD 1.2). Anxiety levels were lower in patients who had recently received sedatives or opioids but were not related to heart rate or blood pressure.

• Conclusions The Faces Anxiety Scale is a valid means of measuring anxiety in intensive care patients. Anxiety is common in these patients and is often moderate to severe.
Equivalence of the Bioimpedance and Thermodilution Methods in Measuring Cardiac Output in Hospitalized Patients With Advanced, Decompensated Chronic Heart Failure
Authors: Albert Nancy M. , Hail Melanie D. , Li Jianbo , Young James B.
Published: November 2019

• Background An accurate and reliable noninvasive method for determining cardiac output/cardiac index would be valuable for patients with acutely decompensated advanced systolic heart failure.

• Objectives To determine whether a correlation exists for cardiac output and index determined by using bioimpedance and thermodilution in patients with acutely decompensated complex heart failure and if differences between results with the 2 methods could be explained by the patients’ advanced condition.

• Methods Cardiac output and index were determined by using bioimpedance and thermodilution in 33 patients. Echocardiographic and electrocardiographic data were assessed to determine if differences between results with the 2 methods could be explained by the patients’ advanced condition. Concordance correlation coefficients and Bland-Altman agreement between methods were calculated.

• Results Four patients were excluded from analysis because reliable measurements could not be obtained; the remaining 29 patients constituted the study population. Mean cardiac outputs determined by thermodilution and bioimpedance were 5.48 and 5.40 L/min, respectively (ρc =0.89, P < .001), and mean cardiac indexes were 2.67 and 2.65 (ρc = 0.82, P < .001). Mean bias (limits of agreement) between data pairs was 0.08 (−0.18 to 0.35) L/min (P = .52) for cardiac output and 0.03 (−0.097 to 0.16; P = .61) for cardiac index. Six data pairs (21%) had an absolute percent difference greater than 15%. Of these, 50% had a higher thermodilution value.

• Conclusion Determinations of cardiac output and index by both methods were significantly correlated. Mean bias between the 2 methods was small, suggesting clinical utility for bioimpedance in patients with complex decompensated heart failure.
Actigraphy in the Critically Ill: Correlation With Activity, Agitation, and Sedation
Authors: Grap Mary Jo , Borchers C. Todd , Munro Cindy L. , Elswick R. K. , Sessler Curtis N.
Published: November 2019

Objectives To determine the feasibility of continuous measurement of limb movement via wrist and ankle actigraphy (an activity measure) in critically ill patients and to compare actigraphy measurements with observed activity, subjective scores on sedation-agitation scales, and heart rate and blood pressure of patients.

• Methods In a prospective, descriptive, correlational study, all activity of 20 adult patients in medical and coronary care units in a university medical center were observed for 2 hours and documented. Wrist and ankle actigraphy, heart rate, and systolic and diastolic blood pressure data were collected every minute. The Comfort Scale and the Richmond Agitation-Sedation Scale were completed at the beginning of the observation period and 1 and 2 hours later.

•Results Wrist actigraphy data correlated with scores on the Richmond Agitation-Sedation Scale (r = 0.58) and the Comfort Scale (r = 0.62) and with observed stimulation and activity events of patients (r = 0.45). Correlations with systolic, diastolic, and mean arterial pressures were weaker. Wrist and ankle actigraphy data were significantly correlated (r = 0.69; P < .001); however, their mean values (wrist, 418; ankle, 147) were significantly different (t = 5.77; P < .001).

• Conclusions Actigraphy provides a continuous recording of patients’ limb movement. Actigraphy measurements correlate well with patients’ observed activity and with subjective scores on agitation and sedation scales. Actigraphy may become particularly important as a continuous measurement of activity for use in behavioral research and may enhance early recognition and management of the excessive activity that characterizes agitation.
Family Presence During Resuscitation: A Critical Review of the Literature
Authors: Halm Margo A.
Published: November 2019

Presence of patients’ families during resuscitation has emerged as an important practice issue, sparking considerable controversy worldwide. Early advocates of allowing patients’ families to be present during resuscitation faced more resistance than did current advocates because the former had little or no scientific research results to support their ideas. In the past 15 years, a number of quantitative studies, especially descriptive surveys, have been conducted. Qualitative researchers have also explored the lived experience of family members present during resuscitation and less commonly the perspectives of patients and healthcare providers. In this review of the literature, the current state of the science is critically reviewed and the ethical-theoretical perspectives of respective researchers and staff participants in the reviewed studies are discussed. Surveys were used to collect data in most studies to date. Limitations of these designs include small convenience samples, low response rates, use of retrospective surveys and the associated potential selection bias, and lack of consistency in survey instruments, factors that make comparison of findings between studies difficult. Recommendations to address the gaps in the current state of knowledge about family members’ presence during resuscitation are discussed. Experimental and qualitative methods are especially needed to investigate the effect of family presence during resuscitation on patients, families, nurses and physicians, and other multidisciplinary staff members.
Assessing Nutritional Status in Chronically Critically Ill Adult Patients
Authors: Higgins Patricia A. , Daly Barbara J. , Lipson Amy R. , Guo Su-Er
Published: November 2019

• Background Numerous methods are used to measure and assess nutritional status of chronically critically ill patients.

• Objectives To discuss the multiple methods used to assess nutritional status in chronically critically ill patients, describe the nutritional status of chronically critically ill patients, and assess the relationship between nutritional indicators and outcomes of mechanical ventilation.

• Methods A descriptive, longitudinal design was used to collect weekly data on 360 adult patients who required more than 72 hours of mechanical ventilation and had a hospital stay of 7 days or more. Data on body mass index and biochemical markers of nutritional status were collected. Patients’ nutritional intake compared with physicians’ orders, dieticians’ recommendations, and indirect calorimetry and physicians’ orders compared with dieticians’ recommendations were used to assess nutritional status. Relationships between nutritional indicators and variables of mechanical ventilation were determined.

• ResultsInconsistencies among nurses’ implementation, physicians’ orders, and dieticians’ recommendations resulted in wide variations in patients’ calculated nutritional adequacy. Patients received a mean of 83% of the energy intake ordered by their physicians (SD 33%, range 0%–200%). Patients who required partial or total ventilator support upon discharge had a lower body mass index at admission than did patients with spontaneous respirations (Mann-Whitney U = 8441, P = .001).

• Conclusions In this sample, the variability in weaning progression and outcomes most likely reflects illness severity and complexity rather than nutritional status or nutritional therapies. Further studies are needed to determine the best methods to define nutritional adequacy and to evaluate nutritional status.
Preventing Respiratory Complications of Tube Feedings: Evidence-Based Practice
Authors: Metheny Norma A.
Published: November 2019

The most dreaded complication of tube feedings is tracheobronchial aspiration of gastric contents. Strong evidence indicates that most critically ill tube-fed patients receiving mechanical ventilation aspirate gastric contents at least once during their early days of tube feeding. Those who aspirate frequently are about 4 times more likely to have pneumonia develop than are those who aspirate infrequently. Although a patient’s illness might not be modifiable, some risk factors for aspiration can be controlled; among these are malpositioned feeding tubes, improper feeding site, large gastric volume, and supine position. A review of current research-based information to support modification of these risk factors is provided.
Evaluation of Nursing Work Effort and Perceptions About Blood Glucose Testing in Tight Glycemic Control
Authors: Aragon Daleen
Published: November 2019

• Background Tight glycemic control is important in critically ill patients and involves insulin infusions and monitoring of blood glucose levels. Hourly measurements of blood glucose levels and adjustments of intravenous insulin doses require additional work by nurses.

• Objectives To evaluate the nursing work incurred with and nursing perceptions about tight glycemic control and blood glucose monitoring.

• Methods A variety of intensive care units were studied. Surveys were used to gain information about nurses’ perceptions. Time-in-motion observations were used to determine the time taken to measure blood glucose levels and adjust insulin doses.

• Results Nurses thought that tight glycemic control was important and that the work associated with it was substantial. Nurses thought that easier and automated forms of blood glucose monitoring are needed. They preferred using an arterial catheter to obtain blood samples to avoid excessive finger sticks. The total number of blood glucose measurements was 77 954. The mean time taken for hourly blood glucose monitoring and adjustment of insulin doses was 4.72 minutes. The estimated costs of time spent on glycemic control during a 1-year period were $182 488 for nurses’ salaries and $58 500 for supplies.

• Conclusions Although most nurses endorse tight glycemic control, the work associated with it is burdensome and costly. Because up to 2 hours might be required for tight glycemic control for a single patient in a 24-hour period, the costs in time and money are high. Easier clinical methods for monitoring blood glucose levels are needed.
Visitation policies in the ICU: a time for change
Authors: Hamner JB
Published: November 2019

The belief that visitation restrictions in the ICU are for the patient's good is not fully supported by research. However, there are no firm conclusions regarding how visitation decisions should be made. This paper suggests that decisional control over visitation be given to the patient and that, with the nurse functioning as a patient advocate, individualization of visitation be practiced. It is up to nursing to institute changes in visitation of the critical care patient.
Acute esophageal bleeding and endoscopic injection sclerotherapy
Authors: Pierce JD , Wilkerson E , Griffiths SA
Published: November 2019

Endoscopic injection sclerotherapy in the critical care setting is a recently developed method for controlling bleeding from esophageal varices. Since this therapy is often employed as an emergency measure, nurses in ERs and ICUs should be familiar with the procedure. The enclosed outline can be modified to fit the needs of individual physicians, units, and institutions.
Managing the challenge of IABP therapy
Authors: Shoulders-Odom B
Published: November 2019

The nurse's role requires the operation of the IABP, while at the same time, the ability to deliver quality nursing care. Knowledge of physiology, coordination of the principles of timing with hemodynamic effects, and skillful problem solving assure critical care nurses that they can effectively manage the IABP challenge.
Positive and negative criticism: strategies for professional growth
Authors: Davidhizar R , Wysong PR
Published: November 2019

Criticism is a common experience in critical care for both the novice and experienced nurse. Assisting staff to react positively to criticism presents a challenge to the critical care nurse manager and an opportunity to turn what frequently is a negative situation into a phenomenon that builds morale and relationships. Whether criticism is being given or received, it is up to the nurse manager to facilitate positive relationships in the critical care environment.
A three-dimensional geological model of the Paleozoic bedrock of southern Ontario
Authors: Carter T R , Brunton F R , Clark J K , Fortner L , Freckelton C , Logan C E , Russell H A
J , Somers M , Sutherland L , Yeung K H
Published: November 2019

A regional three-dimensional (3-D) lithostratigraphic model of the Paleozoic bedrock of southern Ontario has been completed. The model encompasses the entire Phanerozoic succession of southern Ontario (110 000 km2), consisting of over 1500 m of sedimentary strata
straddling regional arch, or forebulge, zones separating the Appalachian foreland basin from the Michigan structural basin. This initiative provides an unprecedented regional 3-D perspective and digital framework based on an updated regional lithostratigraphic chart. Constructed using Leapfrog
Works, an implicit modelling software application, the model format can readily support numeric groundwater-flow modelling.
Fifty-four Paleozoic bedrock layers representing 70 formations, as well as the Precambrian basement and overlying unconsolidated sediment, were modelled at a spatial resolution of 400 m. Borehole records in Ontario's public petroleum well database (Ontario Petroleum Data System (OPDS)) were the
principal data source, supplemented by Ontario Geological Survey (OGS) deep boreholes, measured sections, control points and Michigan boreholes. A newly revised digital bedrock topography surface combined with revised subcrop geology and digitized 3-D surface polyline and point constraints were used
to better align the modelled layers and their extrapolation to the subcrop surface. Model development was an iterative cycle of interim modelling, expert geological appraisal, and quality assurance and control (QA/QC) editing of geological data using geophysical logs, drill cuttings and core,
supplemented by manual editing of model layers. The 3-D model provides a robust representation of regional bedrock geology.
A properly constructed borehole database and its supporting information is an essential requirement for construction of a 3-D model, but data errors, inconsistencies, data gaps, location errors, etc. can compromise the reliability of the model. From 2015 to 2018, project geologists and geological
contract staff of the Oil, Gas and Salt Resources Library completed edits to 30 320 formation tops in a total of 7812 wells, resulting in a revised data set and permanent improvements to the petroleum well database. This report highlights the importance of QA/QC of well data, specifically formation
top identification, and summarizes the data improvements made in support of the present 3-D model. No seismic data was available.
Management of recurrent aneurysms after endovascular coiling: A Fujita experience
Authors: Kutty Raja , Kumar Ambuj , Yamada Yasuhiro , Tanaka Riki , Kannan Satish , Ravisankar Vigneshwar , Musara Aaron , Miyatani Kyosuke , Higashiguchi Saeko , Takizawa Katsumi , Kawase Tsukasa , Kato Yoko
Published: November 2019

Introduction: Microsurgical clipping and Endovascular coiling (EC) are both effective alternatives in the management of intracranial aneurysms. EC has been shown to be associated with the risk of recurrent aneurysm (RA) growth. Considering the minimally invasive nature of this procedure, the management of intracranial aneurysms has been skewed toward EC, especially in the developed world. In this scenario, there has been an upsurge of RAs after EC. Since the optimal management of these RAs has not been defined, they pose a unique challenge to the treating surgeons. Aims and Objectives: The aim of this study is to elucidate the optimal management of RAs after EC. Materials and Methods: Medical records of all patients who underwent surgery for RAs were reviewed from the period January 2014 to March 2019. The demographic and angiographic patterns of the patients and operative techniques and complications were studied. The outcome was dichotomized into good and bad depending on the Glasgow outcome scale (GOS). Results: There were four cases of RAs operated in our institution between the above-mentioned period. There were varied differences between the initial coiling and time to recurrences. All four patients were operated under neuromonitoring. Three underwent clipping and one patient underwent clipping with bypass. All four patients had good outcome with a GOS of 5/5. Conclusion: Operations for RAs constitute many technical challenges and require a lot of expertise. Such surgeries are recommended in high-volume centers, with sufficient experience in both clipping and cerebral bypass.
Infection with spinal instrumentation: A 20-year, single-institution experience with review of pathogenesis, diagnosis, prevention, and management
Authors: Kalfas Fotios , Severi Paolo , Scudieri Claudia
Published: November 2019

Objective and Importance: Instrumentation has become an integral component in the management of various spinal pathologies. The rate of infection varies from 2% to 20% of all instrumented spinal procedures. Postoperative spinal implant infection places patients at risk for pseudo-arthrosis, correction loss, spondylodiscitis, and adverse neurological sequelae and increases health-care costs. Materials and Methods: We performed a cohort study of 1065 patients who underwent instrumented spinal procedures in our institution between 1995 and 2014. Fifty-one patients (4.79%) contracted postoperative spinal infection. Isolated bacterial species, infection severity, diagnosis/treatment timing, surgical/medical strategy treatment, and patient's medical background were evaluated to assess their relationship with management outcome. Results: Multiple risk factors for postoperative spinal infection were identified. Infections may be early or delayed. C-reactive protein and magnetic resonance imaging are important diagnostic tools. Prompt diagnosis and aggressive therapy (debridement and parenteral antibiotics) were responsible for implant preservation in 49 of 51 cases, whereas implant removal noted in two cases was attributed to delayed treatment and uncontrolled infection with implant loosening or late infection with spondylodesis. Infection in the setting of instrumentation is more difficult to diagnose and treat due to biofilm. Conclusion: Retention of the mechanically sound implants in early-onset infection permits fusion to occur, whereas delayed treatment and multiple comorbidities will most likely result in a lack of effectiveness in eradicating the infecting pathogens. An improved understanding of the role of biofilm and the development of newer spinal implants has provided insight into the pathogenesis and management of infected spinal implants. It is important to accurately identify and treat postoperative spinal infections. The treatment is multimodal and prolonged.
Endoscopic transsphenoidal approach in treatment of germinomas of the chiasmosellar region
Authors: Kutin Maxim , Fomichev Dmitry , Shkarubo Alexey , Chernov Ilia , Sharipov Oleg , Andreev Dmitry , Ismailov Denilbek , Mikhailov Nikita , Kobyakov Grigoriy , Trunin Yuriy , Astafyeva Ludmila , Abdilatipov Abdishukur , Poddubsky Artem , Kalinin Pavel
Published: November 2019

Introduction: Germinogenic central nervous system (CNS) tumors represent a heterogeneous group of tumors, constituting approximately 0.4% of all primary brain tumors. Removal of the tumor has no prognostic value. In “pure” primary germinomas of the CNS, the alpha-fetoprotein and human chorionic gonadotropin levels are within normal limits, and no specific biochemical tumor markers currently exist for this tumor type, making histological verification crucial for the choice of treatment tactics. When the tumor is located in the chiasmosellar region, one of the possible verification methods is endoscopic endonasal transsphenoidal biopsy. Objective: the main objective of the study is to demonstrate the feasibility and safety of endoscopic transsphenoidal approach for histological verification of primary germinomas of the CNS with chiasmosellar localization. Materials and Methods: The current study includes 13 patients with “pure” germinomas of the chiasmosellar region who underwent endoscopic endonasal surgical interventions with subsequent treatment according to the “Germinoma 2008” protocol. Results: The extent of surgical intervention ranged from biopsy (4) to partial (5) and total (4) removal of the tumor. In all cases, histological verification of the diagnosis was achieved and none of the patients presented with cerebrospinal fluid leaks and/or meningitis in the postoperative period, allowing to evaluate endoscopic intervention in our patient series as safe and effective. Two out of 13 patients were lost to follow-up. Conclusion: The endoscopic endonasal approach for histological verification and removal of chiasmosellar region germinomas is safe, and in some cases, less traumatic for the patient than transcranial and transventricular approaches.
Microsurgical clipping of distal basilar trunk aneurysm during adenosine-induced profound hypotension
Authors: Sai Kiran Narayanam , Kiran Kumar Veldurti , Kumar Valluri , Agrawal Amit
Published: November 2019

A 46-year-old male presented with a history of sudden severe headache 1 week back, altered sensorium and right hemiparesis for 2 days. On examination, Glasgow Coma Scale (GCS) was E4V4M6 and the patient had right hemiparesis (power – 4/5). Computed tomography (CT) revealed diffuse subarachnoid hemorrhage (Fisher's Grade III). CT angiogram revealed distal basilar trunk aneurysm arising between the origin of the left posterior cerebral artery and superior cerebellar artery, ectatic dilatation of distal basilar trunk, and a left middle cerebral artery (MCA) bifurcation aneurysm. Basilar trunk aneurysm was approached through subtemporal route and aneurysm was clipped during adenosine-induced profound hypotension (AIPH) without application of temporary clip. Single bolus 6 mg of adenosine was given, and aneurysm was successfully clipped during AIPH (systolic <60 mmHg). There were no complications related to adenosine. Ectatic part of distal basilar trunk was wrapped with Teflon. The left MCA bifurcation aneurysm was clipped in the same session. At 3-month follow-up, the patient's sensorium was normal (GCS-E4V5M6) and the right hemiparesis improved (4+/5). Adenosine enhances the safety of clipping these aneurysms by providing transient cardiac arrest or profound hypotension. In developing countries, microsurgical clipping is a cost-effective treatment option for basilar artery aneurysms.
One-stage operation with ipsilateral two-piece craniotomies for a case of subarachnoid hemorrhage with multiple intracranial aneurysms
Authors: Tsunoda Sho , Yoshikawa Gakushi , Ishikawa Osamu
Published: November 2019

Subarachnoid hemorrhage (SAH) with multiple intracranial aneurysms is common, but the difficulties often arise in determining treatment strategy in the acute phase. We experienced a case of SAH with distal anterior cerebral artery aneurysm coexisting with middle cerebral artery and anterior communicating artery aneurysms, in which it was difficult to identify the precise rupture site preoperatively, and both pterional approach and interhemispheric approach were required in the acute phase of SAH. However, we could treat whole aneurysms in one stage and obtained an excellent outcome using our surgical procedure with ipsilateral frontotemporal and frontal parasagittal craniotomies through a single skin incision.
Endovascular rescue strategies for nonopening of pipeline device: Report of two cases
Authors: Mahajan Anshu , Banga Vinit , Chatterjee Apratim , Goel Gaurav
Published: November 2019

We report two cases of rescue strategies for nonopening of Pipeline flow-diverter device for the treatment of intracranial aneurysm. The first patient, a 65-year-old female, presented with complaints of headache for 3 months and was found to have giant supraclinoid internal carotid artery (ICA) (ophthalmic segment) aneurysm. We planned endovascular partial coiling and flow-diverter placement for the treatment of ICA aneurysm. During the progressive deployment of PED, there was nonopening of Pipeline embolization device (PED) at its proximal end. We tried multiple attempts to navigate Marksman microcatheter over the PED delivery microwire and Echelon microcatheter over the Traxcess microwire across the pinched site, but we were not able to achieve success. After that, we tried opposite transcranial approach across prominent anterior communicating artery with the Synchro and Transcend microguidewire which finally resulted in the opening of the device; however, there was acute extravasation of dye on check angiogram. Thus, our technical success turned into disaster. The second patient, a 55-year-old female, presented with complaint of seizures for 3 months due to mass effect of cavernous sinus aneurysm. Pipeline Flex flow-diverter placement was done across the aneurysm neck. During the progressive deployment of device, there was nonopening of the mid and proximal segment of Pipeline Flex which was successfully managed by intra-Navien deployment of device followed by simultaneous push of Marksman microcatheter and pull of Navien catheter. In our case series, two rescue strategies were applied to successfully open the proximal constricted portion of Pipeline Flex; however, technical success in one case resulted in unmanageable disasters. Thus, transcranial rescue strategy for opening the constricted Pipeline Flex device should be cautiously used in our endovascular practice.
Atypical symptomatic bilateral spontaneous cavernous carotid aneurysm with systemic vessel wall pathology in young female: A rare case report
Authors: Miyatani Kyosuke , Korde Paresh , Yamada Yasuhiro , Kawase Tsukasa , Takizawa Katsumi , Kato Yoko
Published: November 2019

Bilateral cavernous carotid aneurysm (CCA) is a rare entity. Its association with connective tissue disorder makes the diagnosis and treatment of symptomatic patient an enigma. We present a case report of a 25-year-old female medical student presented to us with bilateral spontaneous atypically symptomatic CCA with incidentally diagnosed case of Ehlers–Danlos syndrome. Both surgical and endovascular options of treatment were weighed and were ultimately treated satisfactorily by high-flow bypass with carotid artery ligation with an insurance bypass.
A 5-year follow-up of intracranial arterial dolichoectasia: A case report and review of literature
Authors: Rathore Lavlesh , Yamada Yashiro , Kawase Tsukasa , Kato Yoko , Senapati Satya
Published: November 2019

A patient with multiple dolichoectasia of the intracranial cerebral artery was followed sequentially with clinical and radiological progression of disease in the past 5 years. The patient was treated in multiple stages in the past 5 years with the endovascular and microsurgical clipping method. The maximum diameter of each major intracranial artery segment was recorded and compared in the follow-up year. The progression in size of the dolichoectatic segment was observed in spite of surgical intervention. In review diagnostic criteria, etiopathogenesis and treatment options have been discussed.
Anatomical and biomechanical study of the lumbar interspinous ligament
Authors: Iwanaga Joe , Simonds Emily , Yilmaz Emre , Schumacher Maia , Patel Mayank , Tubbs R
Published: November 2019

Objective: The lumbar interspinous ligaments (ISLs) are thin and short fibers connecting adjacent spinous processes. However, their morphology is variably described and their biomechanics are not well understood. Therefore, the purpose of this study was to assess the anatomy and biomechanics of the lumbar ISL. Materials and Methods: Five fresh frozen cadaveric specimens were dissected posteriorly to reveal and study the lumbar ISL. Measurements of the ligaments included the anterior vertical height (length A), the posterior vertical height (length P), and the length (length H) at each lumbar level. Next, 17 lumbar vertebral levels from 6 cadaveric specimens were used for tensile strength testing. The ISLs were subjected to vertically controlled increasing manual tension. The force necessary to disrupt the ISL was recorded. Results: All the ISLs ran horizontally in an anterior–posterior direction with a slight curve. The average of length A, length P, and length H on the right sides was 9.82, 9.57, and 20.12 mm, respectively. The average of length A, length P, and length H on the left sides was 11.56, 12.01, and 21.42 mm, respectively. The mean tensile strength of the ISL was 162.33 (N) at L1/2, 85.67 (N) at L2/3, and 79 (N) at L3/4. There was a significant difference in the tensile force between L1/2 and L2/3 and L1/2 and L3/4 (P < 0.05). The ligaments became weaker with a descent along the lumbar levels. Conclusion: The results of this study might help surgeons understand pathology/trauma of the lumbar vertebral region.
Traumatic vertebral body second lumbar over third lumbar retrolisthesis in a child: Reporting the first case along with the review of relevant literature
Authors: Kaushal-Deep Singh , Bhat Abdul
Published: November 2019

Traumatic retrolisthesis of the lumbar vertebrae is a rare entity in children. Only four such cases, two cases each of first lumbar–second lumbar (L1–L2) and L5-S1 retrolisthesis in children, have been reported so far in the English scientific literature. Here, we report a traumatic retrolisthesis of the L2 vertebra in an 8-year-old male child. He was injured when he lost control while playing, skidded, and fell into a 1-m deep drainage system hole. He presented with backache and urinary retention. His plain radiographs and noncontrast computed tomography of the lumbosacral spine revealed Meyerding Grade II retrolisthesis of the L2 vertebra over the third. The magnetic resonance imaging of the affected area revealed no significant canal narrowing, and there was no spinal cord compression or contusion. A urodynamic study was done which revealed a normal bladder function. The patient was given a trial of spontaneous urination by removing the Foley's catheter after 5 days of injury, and he passed urine normally. The patient was managed conservatively. He was discharged on day 7 with the advice of complete bed rest of 6 weeks and thoracolumbosacral orthoses. The patient has been in follow-up for the past 15 months, and his listhesis has completely resolved. The patient is ambulatory with no neurodeficit. This case is being presented in view of rarity. This is the first case report of L2 over L3 retrolisthesis in a child.
A Man with Diarrhea
Authors: Rajini Kayalvizhi , Solomon T. Rajkumar , Arumugham Aravind , Rangachari Balamurali
Published: November 2019

Diarrhea, a common presenting complaint which we come across in our day‑to‑day practice, is often self‑limited but can be challenging at times. Here, we report one such patient. A 54‑year‑old male presented with diarrhea, abdominal pain, anorexia, and weight loss. Routine blood and stool examination was not helpful. A colonoscopy done elsewhere showed a fistulous opening in the anal canal for which he underwent a fistulectomy. Esophagogastroduodenoscopy revealed severe esophagitis, multiple duodenal ulcers, and a fundic gland polyp from which biopsies were taken. The fundic gland polyp showed oxyntic gland hyperplasia. Basal acid output and serum fasting gastrin subsequently measured were also high. A diagnosis of Zollinger–Ellison syndrome was made, and the patient was started on high‑dose proton‑pump inhibitors, to which he had excellent response. Repeat endoscopy showed resolutions of all lesions. Endoscopic ultrasound (EUS) and DOTA (Gallium (68Ga) DOTA-TATE) scan revealed a tumor in the duodenum and pylorus, respectively. On surgical exploration, the tumor was identified in the second part of the duodenum and was removed. The patient has remained asymptomatic since then.
Pancreatic Cancer Masked by Acute Pancreatitis as well as an Unusual Iatrogenic Complication
Authors: Rana Surinder Singh , Gorsi Ujjwal , Gupta Pankaj , Sharma Ravi , Basher Rajender , Dhalaria Lovneet , Gupta Rajesh
Published: November 2019

A 62‑year‑old female presented with abdominal pain and was diagnosed as acute on chronic pancreatitis based on elevated serum amylase and imaging findings. The pancreatic duct was dilated with abrupt cutoff at neck of pancreas, but no mass was visualized. Positron emission tomography‑computed tomography (PET‑CT) revealed a fluorodeoxyglucose (FDG) avid lesion in the neck of the pancreas but ultrasound (USG)‑guided fine‑needle aspiration (FNA) from the lesion revealed only inflammatory cells. Endoscopic ultrasound, done 2 days after USG‑guided FNA, revealed pseudoaneurysm (PA) in the neck of pancreas that was confirmed on CT angiography. The PA was occluded by USG‑guided percutaneous cyanoacrylate injection. As pain persisted, repeat PET CT was done which revealed FDG avidity around the cyanoacrylate cast as well in multiple small hypodense lesions in the right lobe of the liver. USG‑guided FNA from both the liver lesion as well
as the periphery of the glue cast revealed features of adenocarcinoma. We herein report a case of pancreatic adenocarcinoma that presented as acute pancreatitis and got masked because of formation of PA consequent to USG‑guided FNA.
The flux limited Keller–Segel system; properties and derivation from kinetic equations
Authors: Perthame Benoît , Vauchelet Nicolas , Wang Zhian
Published: November 2019

The flux limited Keller–Segel (FLKS) system is a macroscopic model describing bacteria motion by chemotaxis which takes into account saturation of the velocity. The hyperbolic form and some special parabolic forms have been derived from kinetic equations describing the run and tumble process for bacterial motion. The FLKS model also has the advantage that traveling pulse solutions exist as observed experimentally. It has attracted the attention of many authors recently.

We design and prove a general derivation of the FLKS departing from a kinetic model under stiffness assumption of the chemotactic response and rescaling the kinetic equation according to this stiffness parameter. Unlike the classical Keller–Segel system, solutions of the FLKS system do not blow-up in finite or infinite time. Then we investigate the existence of radially symmetric steady state and long time behaviour of this flux limited Keller–Segel system.
Repentance
Authors: Woll Josephine , Youngblood Denise J.
Published: November 2019

Tengiz Abuladze’s allegorical film, made in Georgia, is the best known film of the perestroika and glasnost years. With its outspoken and controversial reference to the Stalin era and Stalin's place in the Soviet psyche, ‘Repentance’ was originally shelved but ultimately released in 1986 to widespread popular and critical acclaim.

This _KINOfile_ investigates the production, context and critical reception of the film, the people who made it, and provides an analysis of the film itself and its place in world cinema.
The TV Detective
Authors: Piper Helen
Published: November 2019

What makes British television crime drama so perennially popular, both in the UK and internationally? What are the attractions and pleasures of these shows? How are detectives positioned in relation to viewers' national and collective experience of the 'everyday'? This book addresses these questions, examining the trends evident in a range of series – including A Touch of Frost, Lewis, Cracker, Life on Mars and the more recent Luther – in the context of their broader social meaning. Helen Piper develops a compelling argument regarding the cultural relevance of some of the more popular and powerful television detectives, claiming that theirs is a privileged role as the licensed "voices" of dissent. The discontented TV detective, she suggests, may serve to express a broader sense of cultural malaise.
La Haine
Authors: Vincendeau Ginette
Published: November 2019

La Haine is a cult classic with cinema audiences, recently re-released and available on DVD. Ginette Vincendeau is top authority internationally on French cinema, who writes (e.g. Sight and Sound) and broadcasts (e.g. Front Row Radio 4) on it regularly. It is a hugely enjoyable, exciting book written with great panache and accessibility. Released in 1995, La Haine is the black and white chronicle of 24 hours in the life of a mixed-race young male trio from a run-down Parisian suburb. The work of a - then - unknown young team, became hugely and unexpectedly successful, launching director Mathieu Kassovitz and lead player Vincent Cassel to stardom. Vincendeau provides a thorough understanding of the context of the film's making, both in terms of the film industry and of French society, of the film's narrative tension, stylistic sophistication and ideological ambiguity and of its extraordinary success nationally and internationally. She thus explains why, out of so many films about disaffected youth, La Haine is the one that has caught the international imagination.
The Apu Trilogy
Authors: Robinson Andrew
Published: November 2019

"I can never forget the excitement in my mind after seeing 'Pather Panchali'", noted Akira Kurosawa. Satyajit Ray's three films about the boyhood, adolescence and manhood of Apu, Pather Panchali (1955), Aparajito (1956) and The World of Apu (1959) - collectively known as The Apu Trilogy - are established classics of world cinema. The Trilogy was the chief reason for Satyajit Ray's receiving an Academy Award for lifetime achievement in 1992, just before his death.

This book by Ray's biographer and world authority Andrew Robinson is the first full study of the Trilogy. Robinson - who came to know the director well during the last decade of his career - covers the literary and cultural background to the films, their production, their music composed by Ravi Shankar, their aesthetic value, and their complex critical reception in the East and the West, from 1955 up to the present day. Extensively and beautifully illustrated and a pleasure to read, The Apu Trilogy will appeal to anyone captivated by the unique world created by Satyajit Ray.