bluuebunny/crossref_metadata_2025 huggingface dataset:
Penerapan Metode SDLC Waterfall Dalam Perancangan Sistem Informasi Administrasi Keuangan Berbasis Desktop
Authors: Dharmawan Weiskhy Steven , Purwaningtias Deasy , Risdiansyah Deni
Published: February 2019

erdasarkan penelitian yang telah dilakukan pada Kantor Kecamatan Pengkadan diperoleh bahwa suatusistem yang diterapkan belum menggunakan teknologi komputerisasi dalam proses kegitannya sehari.Berdasarkan penelitian tersebut penulis mencoba membuat sebuah rancangan aplikasi guna menunjangaktivitas kegiatan perusahaan dengan menggunakan bahasa pemrograman VB.NET. Untuk metodepengembangan software dilakukan dengan menggunakan metode SDLC Waterfall. Dengan penggunaanaplikasi ini diharapkan dapat mempermudah dan mengolah data keuangan, serta mempermudahpembuatan laporan kas masuk dan kas keluar untuk menghasilkan laporan yang jauh lebih baik. Hasilpengamatan dari penelitian yang telah dilakukan pada Kantor Kecamatan Pengkadan, diketahui bahwasistem pencatatan Media kertas merupakan alat yang digunakan untuk mencatat setiap data pada kantortersebut. Akibatnya laporan yang dihasilkan sering terjadi kesalahan karena hilang dan rusaknya buktitransaksi. Berdasarkan permasalahan yang terjadi dibutuhkannya sebuah rancangan system yangterkomputer agar dapat mengurangi humans error pada proses pembuatan laporan maupun prosespencatatan transaksi. Peneliti mengembangkan sebuah rancangan perangkat lunak yang dapat mengatasipermasalahan yang terjadi pada Kantor Kecamatan Pengkadan. Rancangan yang dibuat menggunakanbahasa pemrogramman Visual Studio 2010 dan menerapkan metode SDLC Waterfall sebagai metodpengembangan perangkat lunak. Perangkat lunak ini diharapkan dapat mempermudah proses pencatatanpengolahan data keuangan, mengurangi kemungkinan terjadinya humans error, menghasilkan laporanyang lebih baik dengan waktu yang singkat, dan mempermudah management dalam mengambil keputusan.
A Comparative Analysis of Physiotherapy for Stress Urinary Incontinence after Open or Robotic-Assisted Radical Prostatectomy
Authors: Sehgal Anika , Baverstock Richard , Wright Ian , Frey Candace , Crump Trafford , Carlson Kevin
Published: February 2019

Purpose: We determined whether the patient-reported benefits of physiotherapy for stress urinary incontinence (SUI) symptoms differ significantly between men who have had open prostatectomy and those who have had robotic-assisted laparoscopic prostatectomy. Method: We conducted a retrospective analysis of data collected from the Rapid Access Clinic 4 offered by the Prostate Cancer Centre in Calgary, Alberta. Baseline characteristics were measured at the pre-surgery appointment, including demographics, health factors, and potential risk factors for SUI. Patient-reported SUI symptoms were measured pre- and post-surgery using the global score of the International Consultation on Incontinence Questionnaire–Urinary Incontinence. Results: Data from 56 men were included in the analysis, evenly split between the open and robotic sub-groups. At 3 months post-surgery, no statistically significant differences were found in the factors associated with incontinence between the two sub-groups. There was a statistically significant improvement in self-reported incontinence symptom severity from 3-month to 2-year follow-up for both sub-groups. Physiotherapy did not differentially affect either sub-group in a significant way. Conclusions: The self-reported benefits of physiotherapy for SUI symptoms did not differ significantly between the two types of prostatectomy surgery at 2 years post-surgery.
Radical Modernism, Operatic Failure, andLouis Riel’s Challenge to Reconciliation
Authors: Lee Sherry D.
Published: February 2019

This article contextualizes the dissonant modernist musical language Harry Somers employed for Louis Riel in relation to the internationalist avant-garde of the mid-twentieth century, with its complex political ramifications, and considers the suitability of the opera’s resultant musical-aesthetic challenge to listeners as a reflection of the conflictual and dissident elements of its subject.
Doing Long Work: Critical Perspectives on Indigenous-Settler Collaboration in Canadian Art Music
Authors: Strachan Jeremy , Nickleson Patrick
Published: February 2019

Following the Truth and Reconciliation Commission of Canada’s ninety-four Calls to Action (2015), many art music composers, ensembles, arts organizations, and administrators have taken up the task of decolonization by exploring possible modes of collaboration between settler and Indigenous artists. In this article, the authors report on their experiences as audience members in three recent productions and as witnesses to Indigenous-led discussions to explore trends and problematic assumptions constitutive of these collaborations. Against the ideal of collaboration as a model of social harmony, the authors explore ongoing tensions between settler colonial logics of authorship, collaboration, and appropriation and argue that embracing the discomfort of ally-ship remains key to moving forward in solidarity work in scholarship and creative practice.
Listening to the Lake
Authors: Ingraham Mary I. , Wells Brianna
Published: February 2019

The authors document the collaboration among Westbank First Nation members, Vancouver’s Turning Point Ensemble, and Astrolabe Musik Theatre in creating The Lake / N-ha-a-itk in the Okanagan region in 2014. As a production including a modernist opera by Barbara Pentland and Dorothy Livesay, Syilx dance, song, drumming, storytelling, and an original composition by Leslie Uyeda, The Lake / N-ha-a-itk reorganizes structures of authority and authorship common in opera into a process akin to some forms of “collective creation” or “devised theatre.” The article archives some of the conversations surrounding the collaboration among its creators and suggests that The Lake / N-ha-a-itk offers an important perspective on the ethics, politics, and aesthetics of opera production in Canada today.
A Review of Weed Management Challenges in Organic Peanut Production
Authors: Johnson W. Carroll
Published: February 2019

Organic peanut production is a high-risk cropping system, largely due to difficulties in managing weeds using methods acceptable for certified-organic production. In contrast with conventional peanut production that relies heavily on synthetic herbicides, organic peanut production must use an integrated system to manage weeds. The foundation for an integrated weed management system is cultural weed control which is a system of production practices that promote uniform peanut growth to suppress weeds. Cultural weed control includes practices that promote vigorous early-season peanut growth and lessen chances for weed escapes. Mechanical weed control is based on repeated cultivation using a tine weeder and sweep cultivator to control weeds before they emerge. However, weed control consistency from cultivation is affected by rainfall that can delay scheduled cultivations and hinder implement function. Handweeding is also a form of mechanical weed control that is used to supplement other weed control efforts by controlling escapes. Herbicides derived from natural products and thermal weed control using propane flaming have limited value in organic peanut production due to limited weed control spectra, specifically poor control of annual grasses and perennial weeds. Successful weed management in certified organic peanut production will depend on an integrated system, not a single form of weed control.
The reliability increase of the electric drives for pumping units
Authors: Fedorіv M. Y. , Halushchak I. D. , Kurliak P. О.
Published: February 2019

Improving the quality and reliability of electrical machines is one of the most urgent problems of modern  electrical engineering. Practical data show that the increase of service life and reliability of machines gives better results than the improvement of other technical and economic indicators: efficiency, power factor, utilization factor. The quantitative indicators of reliability can be best determined by the results of statistical processing of the  information obtained when using the products.
An algorithm of the load balancing based on the actual performance of pumping equipment and temporary changes in the connected load via the emergency shutdown of the pumps has been developed to improve the reliability operation and reduce inefficient energy losses. The main advantage of the proposed method is the  analytical design models of optimization, which does not require numerical methods and iterative procedures.
Such principles as active-preventative service and increasing personal responsibility for its quality and  timeliness should be the basis for the organization of workposts service.
Progressive forms of service are the technical re-equipment, modernization of equipment and improvement of production organization, as well as complex methods of the electric drive maintenance and application of the system of standardized tasks.
The endoscopic transpterional port approach: anatomy, technique, and initial clinical experience
Authors: Andrade-Barazarte Hugo , Patel Krunal , Turel Mazda K. , Doglietto Francesco , Agur Anne , Gentili Fred , Tymianski Rachel , Mendes Pereira Vitor , Tymianski Michael , Radovanovic Ivan
Published: February 2019

OBJECTIVE

The evolution of microsurgical and endoscopic techniques has allowed the development of less invasive transcranial approaches. The authors describe a purely endoscopic transpterional port craniotomy to access lesions involving the cavernous sinus and the anterolateral skull base.

METHODS

Through single- or dual-port incisions and with direct endoscopic visualization, the authors performed an endoscopic transpterional port approach (ETPA) using a 4-mm straight endoscope in 8 sides of 4 formalin-fixed cadaveric heads injected with colored latex. A main working port incision is made just below the superior temporal line and behind the hairline. An optional 0.5- to 1-cm second skin port incision is made on the lateral supraorbital region, allowing multiangle endoscopic visualization and maneuverability. A 1.5- to 2-cm craniotomy centered over the pterion is done through the main port, which allows an extradural exposure of the cavernous sinus region and extra/intradural exposure of the frontal and temporal cranial fossae. The authors present a pilot surgical series of 17 ETPA procedures and analyze the surgical indications and clinical outcomes retrospectively.

RESULTS

The initial stage of this work on cadavers provided familiarity with the technique, standardized its steps, and showed its anatomical limits. The clinical ETPA was applied to gain access into the cavernous sinus, as well as for aneurysm clipping and meningioma resection. Overall, perioperative complications occurred in 1 patient (6%), there was no mortality, and at last follow-up all patients had a modified Rankin Scale score of 0 or 1.

CONCLUSIONS

The ETPA provides a less invasive, focused, and direct route to the cavernous sinus, and to the frontal and temporal cranial fossae, and it is feasible in clinical practice for selected indications with good results.
Intraoperative 3D ultrasound–guided resection of diffuse low-grade gliomas: radiological and clinical results
Authors: Bø Hans Kristian , Solheim Ole , Kvistad Kjell-Arne , Berntsen Erik Magnus , Torp Sverre Helge , Skjulsvik Anne Jarstein , Reinertsen Ingerid , Iversen Daniel Høyer , Unsgård Geirmund , Jakola Asgeir Store
Published: February 2019

OBJECTIVE

Extent of resection (EOR) and residual tumor volume are linked to prognosis in low-grade glioma (LGG) and there are various methods for facilitating safe maximal resection in such patients. In this prospective study the authors assess radiological and clinical results in consecutive patients with LGG treated with 3D ultrasound (US)–guided resection under general anesthesia.

METHODS

Consecutive LGGs undergoing primary surgery guided with 3D US between 2008 and 2015 were included. All LGGs were classified according to the WHO 2016 classification system. Pre- and postoperative volumetric assessments were performed, and volumetric results were linked to overall and malignant-free survival. Pre- and postoperative health-related quality of life (HRQoL) was evaluated.

RESULTS

Forty-seven consecutive patients were included. Twenty LGGs (43%) were isocitrate dehydrogenase (IDH)–mutated, 7 (14%) were IDH wild-type, 19 (40%) had both IDH mutation and 1p/19q codeletion, and 1 had IDH mutation and inconclusive 1p/19q status. Median resection grade was 93.4%, with gross-total resection achieved in 14 patients (30%). An additional 24 patients (51%) had small tumor remnants < 10 ml. A more conspicuous tumor border (p = 0.02) and lower University of California San Francisco prognostic score (p = 0.01) were associated with less remnant tumor tissue, and overall survival was significantly better with remnants < 10 ml (p = 0.03). HRQoL was maintained or improved in 86% of patients at 1 month. In both cases with severe permanent deficits, relevant ischemia was present on diffusion-weighted postoperative MRI.

CONCLUSIONS

Three-dimensional US–guided LGG resections under general anesthesia are safe and HRQoL is preserved in most patients. Effectiveness in terms of EOR appears to be consistent with published studies using other advanced neurosurgical tools. Avoiding intraoperative vascular injury is a key factor for achieving good functional outcome.
Various modifications of a vascularized nasoseptal flap for repair of extensive skull base dural defects
Authors: Moon Ju Hyung , Kim Eui Hyun , Kim Sun Ho
Published: February 2019

OBJECTIVE

Endonasal surgery of the skull base requires watertight reconstruction of the skull base that can seal the dural defect to prevent postoperative CSF rhinorrhea and consequent intracranial complications. Although the incidence of CSF leakage has decreased significantly since the introduction in 2006 of the vascularized nasoseptal flap (the Hadad-Bassagasteguy flap), reconstruction of extensive skull base dural defects remains challenging. The authors describe a new, modified vascularized nasoseptal flap for reconstruction of extensive skull base dural defects.

METHODS

A retrospective review was conducted on 39 cases from 2010 to 2017 that involved reconstruction of the skull base with an endonasal vascularized flap. Extended nasoseptal flaps were generated by adding the nasal floor and inferior meatus mucosa, inferior turbinate mucosa, or entire lateral nasal wall mucosa. The authors specifically highlight the surgical techniques for flap design and harvesting of these various modifications of the vascularized nasoseptal flap.

RESULTS

Thirty-nine endonasal vascularized flaps were used to reconstruct skull base defects in 37 patients with nonsurgical or postoperative CSF rhinorrhea. Of the 39 procedures, extended nasoseptal flaps were used in 5 cases (13%). These included 2 extended nasoseptal flaps including the inferior turbinate mucosa and 3 extended nasoseptal flaps including the entire lateral nasal wall mucosa. These 5 extended nasoseptal flaps were used in patients who had nonsurgical CSF rhinorrhea due to extensive skull base destruction by invasive pituitary tumors. All flaps healed completely and sealed off the CSF leaks. Olfactory function slightly decreased in the 3 patients with extended nasoseptal flaps including the entire lateral nasal wall mucosa. One patient experienced nasolacrimal duct obstruction, which was treated by dacryocystorhinostomy. The authors encountered no wound complication in this series, while crusting at the donor site required daily nasal toilette and frequent debridement until the completion of mucosalization, which usually takes 8 to 12 weeks after surgery.

CONCLUSIONS

Extended nasoseptal flaps are a reliable and versatile option that can be used to reconstruct extensive skull base dural defects resulting from destruction by large invasive tumors or complex endoscopic endonasal surgery. An extended nasoseptal flap that includes the entire lateral nasal wall mucosa (360° flap) is the largest endonasal vascularized flap reported to date and may be an alternative for the reconstruction of extensive skull base defects while avoiding the need for additional external approaches.
Embolization of brain arteriovenous malformations with intent to cure: a systematic review
Authors: Wu Eva M. , El Ahmadieh Tarek Y. , McDougall Cameron M. , Aoun Salah G. , Mehta Nikhil , Neeley Om James , Plitt Aaron , Shen Ban Vin , Sillero Rafael , White Jonathan A. , Batjer H. Hunt , Welch Babu G.
Published: February 2019

OBJECTIVE

Endovascular embolization has been established as an adjuvant treatment strategy for brain arteriovenous malformations (AVMs). A growing body of literature has discussed curative embolization for select lesions. The transition of endovascular embolization from an adjunctive to a definitive treatment modality remains controversial. Here, the authors reviewed the literature to assess the lesional characteristics, technical factors, and angiographic and clinical outcomes of endovascular embolization of AVMs with intent to cure.

METHODS

Electronic databases—Ovid MEDLINE, Ovid Embase, and PubMed—were searched for studies in which there was evidence of AVMs treated using endovascular embolization with intent to cure. The primary outcomes of interest were angiographic obliteration immediately postembolization and at follow-up. The secondary outcomes of interest were complication rates. Descriptive statistics were used to calculate rates and means.

RESULTS

Fifteen studies with 597 patients and 598 AVMs treated with intent-to-cure embolization were included in this analysis. Thirty-four percent of AVMs were Spetzler-Martin grade III. Complete obliteration immediately postembolization was reported in 58.3% of AVMs that had complete treatment and in 45.8% of AVMs in the entire patient cohort. The overall clinical complication rate was 24.1%. The most common complication was hemorrhage, occurring in 9.7% of patients. Procedure-related mortality was 1.5%.

CONCLUSIONS

While endovascular embolization with intent to cure can be an option for select AVMs, the reported complication rates appear to be increased compared with those in studies in which adjunctive embolization was the goal. Given the high complication rate related to a primary embolization approach, the risks and benefits of such a treatment strategy should be discussed among a multidisciplinary team. Curative embolization of AVMs should be considered an unanticipated benefit of such therapy rather than a goal.
Prognostic significance of abnormal hematological parameters in severe traumatic brain injury requiring decompressive craniectomy
Authors: Corbett Jade-Marie , Ho Kwok M. , Honeybul Stephen
Published: February 2019

OBJECTIVE

Hematological abnormalities after severe traumatic brain injury (TBI) are common, and are associated with a poor outcome. Whether these abnormalities offer additional prognostic significance over and beyond validated TBI prognostic models is uncertain.

METHODS

This retrospective cohort study compared the ability of admission hematological abnormalities to that of the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials) prognostic model to predict 18-month neurological outcome of 388 patients who required a decompressive craniectomy after severe TBI, between 2004 and 2016, in Western Australia. Area under the receiver operating characteristic (AUROC) curve was used to assess predictors’ ability to discriminate between patients with and without an unfavorable outcome of death, vegetative state, or severe disability.

RESULTS

Of the 388 patients included in the study, 151 (38.9%) had an unfavorable outcome at 18 months after decompressive craniectomy for severe TBI. Abnormalities in admission hemoglobin (AUROC 0.594, p = 0.002), plasma glucose (AUROC 0.592, p = 0.002), fibrinogen (AUROC 0.563, p = 0.036), international normalized ratio (INR; AUROC 0.645, p = 0.001), activated partial thromboplastin time (AUROC 0.564, p = 0.033), and disseminated intravascular coagulation score (AUROC 0.623, p = 0.001) were all associated with a higher risk of unfavorable outcome at 18 months after severe TBI. As a marker of inflammation, neutrophil to lymphocyte ratio was not significantly associated with the risk of unfavorable outcome (AUROC 0.500, p = 0.998). However, none of these parameters, in addition to the platelet count, were significantly associated with an unfavorable outcome after adjusting for the IMPACT predicted risk (odds ratio [OR] per 10% increment in risk 2.473, 95% confidence interval [CI] 2.061–2.967; p = 0.001). After excluding 8 patients (2.1%) who were treated with warfarin prior to the injury, there was a suggestion that INR was associated with some additional prognostic significance (OR 3.183, 95% CI 0.856–11.833; p = 0.084) after adjusting for the IMPACT predicted risk.

CONCLUSIONS

In isolation, INR was the best hematological prognostic parameter in severe TBI requiring decompressive craniectomy, especially when patients treated with warfarin were excluded. However, the prognostic significance of admission hematological abnormalities was mostly captured by the IMPACT prognostic model, such that they did not offer any additional prognostic information beyond the IMPACT predicted risk. These results suggest that new prognostic factors for TBI should be evaluated in conjunction with predicted risks of a comprehensive prognostic model that has been validated, such as the IMPACT prognostic model.
The Computerized General Neuropsychological INPH Test revealed improvement in idiopathic normal pressure hydrocephalus after shunt surgery
Authors: Behrens Anders , Elgh Eva , Leijon Göran , Kristensen Bo , Eklund Anders , Malm Jan
Published: February 2019

OBJECTIVE

The Computerized General Neuropsychological INPH Test (CoGNIT) provides the clinician and the researcher with standardized and accessible cognitive assessments in patients with idiopathic normal pressure hydrocephalus (INPH). CoGNIT includes tests of memory, executive functions, attention, manual dexterity, and psychomotor speed. Investigations of the validity and reliability of CoGNIT have been published previously. The aim of this study was to evaluate CoGNIT’s sensitivity to cognitive change after shunt surgery in patients with INPH.

METHODS

Forty-one patients with INPH (median Mini-Mental State Examination score 26) were given CoGNIT preoperatively and at a postoperative follow-up 4 months after shunt surgery. Scores were compared to those of 44 healthy elderly control volunteers. CoGNIT was administered by either a nurse or an occupational therapist.

RESULTS

Improvement after shunt surgery was seen in all cognitive domains: memory (10-word list test, p < 0.01); executive functions (Stroop incongruent color and word test, p < 0.01); attention (2-choice reaction test, p < 0.01); psychomotor speed (Stroop congruent color and word test, p < 0.01); and manual dexterity (4-finger tapping, p < 0.01). No improvement was seen in the Mini-Mental State Examination score. Preoperative INPH test scores were significantly impaired compared to healthy control subjects (p < 0.001 for all tests).

CONCLUSIONS

In this study the feasibility for CoGNIT to detect a preoperative impairment and postoperative improvement in INPH was demonstrated. CoGNIT has the potential to become a valuable tool in clinical and research work.

Clinical trial registration no.: NCT01618500 (clinicaltrials.gov)
Matching early arterial oxygenation to long-term outcome in severe traumatic brain injury: target values
Authors: Alali Aziz S. , Temkin Nancy , Vavilala Monica S. , Lele Abhijit V. , Barber Jason , Dikmen Sureyya , Chesnut Randall M.
Published: February 2019

OBJECTIVE

The aim of this study was to examine the relationship between early arterial oxygenation thresholds and long-term outcome after severe traumatic brain injury (TBI).

METHODS

In a post hoc analysis of a randomized trial, adults with severe TBI were classified based on exposure to different levels of arterial oxygenation as measured using the average of arterial partial pressure of oxygen (PaO2) values obtained within 24 hours of admission. Potentially important PaO2 thresholds were defined a priori. The primary outcome was Glasgow Outcome Scale–Extended (GOSE) score at 6 months. Secondary outcomes were cognitive outcomes measured using a battery of 9 neuropsychological tests administered at 6 months, and 6-month mortality.

RESULTS

In adjusted analyses, oxygenation thresholds of 150 and 200 mm Hg were associated with better functional outcome at 6 months (adjusted OR for better functional outcome on GOSE 1.82 [95% CI 1.12–2.94] and 1.59 [95% CI 1.06–2.37], respectively) and improved cognitive outcome at 6 months (adjusted beta coefficients for better cognitive percentile across 9 neuropsychological tests: 6.9 [95% CI 1.3–12.5] and 6.8 [95% CI 2.4–11.3], respectively). There was no significant association between oxygenation level and 6-month mortality except at a PaO2 threshold of 200 mm Hg (OR for death 0.36, 95% CI 0.18–0.71). Higher or lower oxygenation thresholds were not associated with functional or cognitive outcome.

CONCLUSIONS

In this observational study, the relationship between early arterial oxygenation and long-term functional and cognitive TBI outcomes appears to be U-shaped. Mild levels of hyperoxemia within the first 24 hours after injury were associated with better long-term functional and cognitive outcomes. These findings highlight the importance of examining balanced oxygen supplementation as a potential strategy to improve TBI outcomes in future research.
Recent trends in North American pediatric neurosurgical fellowship training
Authors: Nadel Jeffrey L. , Scott R. Michael , Durham Susan R. , Maher Cormac O.
Published: February 2019

OBJECTIVE

The goal of this study was to evaluate trends in pediatric neurosurgical fellowship training in North America.

METHODS

From a database maintained by the Accreditation Council for Pediatric Neurosurgery Fellowships (ACPNF), all graduates of ACPNF-accredited pediatric neurosurgery fellowships were identified, and an Internet search was conducted to determine sex, undergraduate and graduate degrees, location and dates of residency and fellowship training, current practice/employment environment, American Board of Neurological Surgery (ABNS) or Fellowship of the Royal College of Surgeons certification status, American Board of Pediatric Neurological Surgery (ABPNS) certification status, and extent of current pediatric-focused practice. The graduates were further studied to determine whether they had completed a neurosurgical residency at a program with an affiliated ACPNF-accredited pediatric neurosurgery fellowship program, and their residency training programs were further classified by whether the program was ranked in the top 50 by NIH funding awards. Each fellowship graduate’s current practice was also ranked in a similar fashion.

RESULTS

There were 391 graduates of ACPNF-accredited pediatric neurosurgery fellowship programs from 1993 to 2018. The number of graduates per year has grown steadily over time, as has the percentage of women, now over 40% compared to zero in the first 3 years of fellowship accreditation in the mid-1990s. Approximately 71% of graduating fellows have a pediatric-focused practice, but only 63% went on to attain ABPNS certification. Of all graduates practicing in the United States, 68% practice in academic settings. Ninety-five percent of graduating fellows who were ABNS board eligible were ABNS certified.

CONCLUSIONS

A study of the graduates of accredited pediatric neurosurgical fellowships from 1993 to 2018 has revealed a growth in the number of graduates from ACPNF-accredited fellowship programs over time. A substantial portion of graduates will practice at least some adult neurosurgery and not go on to obtain ABPNS board certification.
Pontine tumor in a neonate: case report and analysis of the current literature
Authors: Buus-Gehrig Constanze , Lehrnbecher Thomas , Porto Luciana , Becker Martina , Freiman Thomas , Mittelbronn Michel , Bochennek Konrad
Published: February 2019

Tumors of the central nervous system represent the largest group of solid tumors found in pediatric patients. Pilocytic astrocytoma is the most common pediatric glioma, mostly located in the posterior fossa. The majority of brainstem tumors, however, are classified as highly aggressive diffuse intrinsic pontine gliomas (DIPGs) and their prognosis is dismal.

The authors report on the case of a neonate in whom MRI and neuropathological assessment were used to diagnose DIPG. Before initiation of the planned chemotherapy, the tumor regressed spontaneously, and the newborn exhibited a normal neurological development. Meanwhile, Illumina Human Methylation450 BeadChip analysis reclassified the tumor as pilocytic astrocytoma of the posterior fossa.

In conclusion, the authors advocate not initiating immediate intensive therapy in newborns with brain tumors, even with classical appearance of a DIPG; rather, they would like to encourage a biopsy to define the best individual therapeutic approach and avoid ineffective chemotherapy.
Calgary Shunt Protocol, an adaptation of the Hydrocephalus Clinical Research Network shunt protocol, reduces shunt infections in children
Authors: Yang Michael M. H. , Hader Walter , Bullivant Kelly , Brindle Mary , Riva-Cambrin Jay
Published: February 2019

OBJECTIVE

The shunt protocol developed by the Hydrocephalus Clinical Research Network (HCRN) was shown to significantly reduce shunt infections in children. However, its effectiveness had not been validated in a non-HCRN, small- to medium-volume pediatric neurosurgery center. The present study evaluated whether the 9-step Calgary Shunt Protocol, closely adapted from the HCRN shunt protocol, reduced shunt infections in children.

METHODS

The Calgary Shunt Protocol was prospectively applied at Alberta Children’s Hospital from May 23, 2013, to all children undergoing any shunt procedure. The control cohort consisted of children undergoing shunt surgery between January 1, 2009, and the implementation of the Calgary Shunt Protocol. The primary outcome was the strict HCRN definition of shunt infection. Univariate analyses of the protocol, individual elements within, and known confounders were performed using Student t-test for measured variables and chi-square tests for categorical variables. Multivariable logistic regression was performed using stepwise analysis.

RESULTS

Two-hundred sixty-eight shunt procedures were performed. The median age of patients was 14 months (IQR 3–61), and 148 (55.2%) were male. There was a significant absolute risk reduction of 10.0% (95% CI 3.9%–15.9%) in shunt infections (12.7% vs 2.7%, p = 0.004) after implementation of the Calgary Shunt Protocol. In univariate analyses, chlorhexidine was associated with fewer shunt infections than iodine-based skin preparation solution (4.1% vs 12.3%, p = 0.02). Waiting ≥ 20 minutes between receiving preoperative antibiotics and skin incision was also associated with a reduction in shunt infection (4.5% vs 14.2%, p = 0.007). In the multivariable analysis, only the overall protocol independently reduced shunt infections (OR 0.19 [95% CI 0.06–0.67], p = 0.009), while age, etiology, procedure type, ventricular catheter type, skin preparation solution, and time from preoperative antibiotics to skin incision were not significant.

CONCLUSIONS

This study externally validates the published HCRN protocol for reducing shunt infection in an independent, non-HCRN, and small- to medium-volume pediatric neurosurgery setting. Implementation of the Calgary Shunt Protocol independently reduced shunt infection risk. Chlorhexidine skin preparation and waiting ≥ 20 minutes between administration of preoperative antibiotic and skin incision may have contributed to the protocol’s quality improvement success.
Impact of total propofol dose during spinal surgery: anesthetic fade on transcranial motor evoked potentials
Authors: Ushirozako Hiroki , Yoshida Go , Kobayashi Sho , Hasegawa Tomohiko , Yamato Yu , Yasuda Tatsuya , Banno Tomohiro , Arima Hideyuki , Oe Shin , Mihara Yuki , Togawa Daisuke , Matsuyama Yukihiro
Published: February 2019

OBJECTIVE

Intraoperative neuromonitoring may be valuable for predicting postoperative neurological complications, and transcranial motor evoked potentials (TcMEPs) are the most reliable monitoring modality with high sensitivity. One of the most frequent problems of TcMEP monitoring is the high rate of false-positive alerts, also called “anesthetic fade.” The purpose of this study was to clarify the risk factors for false-positive TcMEP alerts and to find ways to reduce false-positive rates.

METHODS

The authors analyzed 703 patients who underwent TcMEP monitoring under total intravenous anesthesia during spinal surgery within a 7-year interval. They defined an alert point as final TcMEP amplitudes ≤ 30% of the baseline. Variations in body temperature (maximum − minimum body temperature during surgery) were measured. Patients with false-positive alerts were classified into 2 groups: a global group with alerts observed in 2 or more muscles of the upper and lower extremities, and a focal group with alerts observed in 1 muscle.

RESULTS

False-positive alerts occurred in 100 cases (14%), comprising 60 cases with global and 40 cases with focal alerts. Compared with the 545 true-negative cases, in the false-positive cases the patients had received a significantly higher total propofol dose (1915 mg vs 1380 mg; p < 0.001). In the false-positive cases with global alerts, the patients had also received a higher mean propofol dose than those with focal alerts (4.5 mg/kg/hr vs 4.2 mg/kg/hr; p = 0.087). The cutoff value of the total propofol dose for predicting false-positive alerts, with the best sensitivity and specificity, was 1550 mg. Multivariate logistic analysis revealed that a total propofol dose > 1550 mg (OR 4.583; 95% CI 2.785–7.539; p < 0.001), variation in body temperature (1°C difference; OR 1.691; 95% CI 1.060–2.465; p < 0.01), and estimated blood loss (500-ml difference; OR 1.309; 95% CI 1.155–1.484; p < 0.001) were independently associated with false-positive alerts.

CONCLUSIONS

Intraoperative total propofol dose > 1550 mg, larger variation in body temperature, and greater blood loss are independently associated with false-positive alerts during spinal surgery. The authors believe that these factors may contribute to the false-positive global alerts that characterize anesthetic fade. As it is necessary to consider multiple confounding factors to distinguish false-positive alerts from true-positive alerts, including variation in body temperature or ischemic condition, the authors argue the importance of a team approach that includes surgeons, anesthesiologists, and medical engineers.
Outcomes in different age groups with primary Ewing sarcoma of the spine: a systematic review of the literature
Authors: Berger Garrett K. , Nisson Peyton L. , James Whitney S. , Kaiser Kristen N. , Hurlbert R. John
Published: February 2019

OBJECTIVE

Ewing sarcoma (ES) is among the most prevalent of bone sarcomas in young people. Less often, it presents as a primary lesion of the spine (5%–15% of patients with ES).

METHODS

A systematic literature search was performed, querying several scientific databases per PRISMA guidelines. Inclusion criteria specified all studies of patients with surgically treated ES located in the spine. Patient age was categorized into three groups: 0–13 years (age group 1), 14–20 years (age group 2), and > 21 (age group 3).

RESULTS

Eighteen studies were included, yielding 28 patients with ES of the spine. Sixty-seven percent of patients experienced a favorable outcome, with laminectomies representing the most common (46%) of surgical interventions. One-, 2-, and 5-year survival rates were 82% (n = 23), 75% (n = 21), and 57% (n = 16), respectively. Patients in age group 2 experienced the greatest mortality rate (75%) compared to age group 1 (9%) and age group 3 (22%). The calculated relative risk score indicated patients in age group 2 were 7.5 times more likely to die than other age groups combined (p = 0.02).

CONCLUSIONS

Primary ES of the spine is a rare, debilitating disease in which the role of surgery and its impact on one’s quality of life and independence status has not been well described. This study found the majority of patients experienced a favorable outcome with respect to independence status following surgery and adjunctive treatment. An increased risk of recurrence and death was also present among the adolescent age group (14–20 years).
Pedicle stress shielding following growing rod implantation: case report
Authors: Cognetti Daniel J. , Samdani Amer F. , Pahys Joshua M. , Groves Mari L. , Hwang Steven W.
Published: February 2019

Growing rod surgery for skeletally immature patients helps correct severe scoliosis while allowing continued spinal column growth. Previous reports have studied vertebral body changes following growing rod surgery, but there are currently no published reports on alterations in pedicle morphology. Given the potential need for definitive spinal fusion with pedicle screw instrumentation, an awareness of changes in pedicle morphology is critical. A morphometric analysis of pedicles was performed using 3D reconstructions of 3 CT scans (preoperative and at 3 and 6 years) obtained in a young girl with infantile idiopathic scoliosis (T7 apex) who underwent unilateral rib-to-spine growing rod (2nd–4th ribs to L1) implantation with lengthening every 6 months for 6 years. The pedicle widths on the growing rod side from T5 to T9 (apex ± 2) were all smaller at 6 years postoperatively than preoperatively, while the same-level pedicles opposite the device significantly increased in width. These findings support anecdotal intraoperative reports by surgeons and provide evidence of pedicle stress shielding due to growing rod distraction and force deprivation.
3-Tesla MRI of deep brain stimulation patients: safety assessment of coils and pulse sequences
Authors: Boutet Alexandre , Hancu Ileana , Saha Utpal , Crawley Adrian , Xu David S. , Ranjan Manish , Hlasny Eugen , Chen Robert , Foltz Warren , Sammartino Francesco , Coblentz Ailish , Kucharczyk Walter , Lozano Andres M.
Published: February 2019

OBJECTIVE

Physicians are more frequently encountering patients who are treated with deep brain stimulation (DBS), yet many MRI centers do not routinely perform MRI in this population. This warrants a safety assessment to improve DBS patients’ accessibility to MRI, thereby improving their care while simultaneously providing a new tool for neuromodulation research.

METHODS

A phantom simulating a patient with a DBS neuromodulation device (DBS lead model 3387 and IPG Activa PC model 37601) was constructed and used. Temperature changes at the most ventral DBS electrode contacts, implantable pulse generator (IPG) voltages, specific absorption rate (SAR), and B1+rms were recorded during 3-T MRI scanning. Safety data were acquired with a transmit body multi-array receive and quadrature transmit-receive head coil during various pulse sequences, using numerous DBS configurations from “the worst” to “the most common.”

In addition, 3-T MRI scanning (T1 and fMRI) was performed on 41 patients with fully internalized and active DBS using a quadrature transmit-receive head coil. MR images, neurological examination findings, and stability of the IPG impedances were assessed.

RESULTS

In the phantom study, temperature rises at the DBS electrodes were less than 2°C for both coils during 3D SPGR, EPI, DTI, and SWI. Sequences with intense radiofrequency pulses such as T2-weighted sequences may cause higher heating (due to their higher SAR). The IPG did not power off and kept a constant firing rate, and its average voltage output was unchanged. The 41 DBS patients underwent 3-T MRI with no adverse event.

CONCLUSIONS

Under the experimental conditions used in this study, 3-T MRI scanning of DBS patients with selected pulse sequences appears to be safe. Generally, T2-weighted sequences (using routine protocols) should be avoided in DBS patients. Complementary 3-T MRI phantom safety data suggest that imaging conditions that are less restrictive than those used in the patients in this study, such as using transmit body multi-array receive coils, may also be safe. Given the interplay between the implanted DBS neuromodulation device and the MRI system, these findings are specific to the experimental conditions in this study.
Nucleus basalis of Meynert neuronal activity in Parkinson’s disease
Authors: Lee Darrin J. , Milosevic Luka , Gramer Robert , Sasikumar Sanskriti , Al-Ozzi Tameem M. , De Vloo Philippe , Dallapiazza Robert F. , Elias Gavin J. B. , Cohn Melanie , Kalia Suneil K. , Hutchison William D. , Fasano Alfonso , Lozano Andres M.
Published: February 2019

OBJECTIVE

Neuronal loss within the cholinergic nucleus basalis of Meynert (nbM) correlates with cognitive decline in dementing disorders such as Alzheimer’s disease and Parkinson’s disease (PD). In nonhuman primates, the nbM firing pattern (5–40 Hz) has also been correlated with working memory and sustained attention. In this study, authors performed microelectrode recordings of the globus pallidus pars interna (GPi) and the nbM immediately prior to the implantation of bilateral deep brain stimulation (DBS) electrodes in PD patients to treat motor symptoms and cognitive impairment, respectively. Here, the authors evaluate the electrophysiological properties of the nbM in patients with PD.

METHODS

Five patients (4 male, mean age 66 ± 4 years) with PD and mild cognitive impairment underwent bilateral GPi and nbM DBS lead implantation. Microelectrode recordings were performed through the GPi and nbM along a single trajectory. Firing rates and burst indices were characterized for each neuronal population with the patient at rest and performing a sustained-attention auditory oddball task. Action potential (AP) depolarization and repolarization widths were measured for each neuronal population at rest.

RESULTS

In PD patients off medication, the authors identified neuronal discharge rates that were specific to each area populated by GPi cells (92.6 ± 46.1 Hz), border cells (34 ± 21 Hz), and nbM cells (13 ± 10 Hz). During the oddball task, firing rates of nbM cells decreased (2.9 ± 0.9 to 2.0 ± 1.1 Hz, p < 0.05). During baseline recordings, the burst index for nbM cells (1.7 ± 0.6) was significantly greater than those for GPi cells (1.2 ± 0.2, p < 0.05) and border cells (1.1 ± 0.1, p < 0.05). There was no significant difference in the nbM burst index during the oddball task relative to baseline (3.4 ± 1.7, p = 0.20). With the patient at rest, the width of the depolarization phase of APs did not differ among the GPi cells, border cells, and nbM cells (p = 0.60); however, during the repolarization phase, the nbM spikes were significantly longer than those for GPi high-frequency discharge cells (p < 0.05) but not the border cells (p = 0.20).

CONCLUSIONS

Neurons along the trajectory through the GPi and nbM have distinct firing patterns. The profile of nbM activity is similar to that observed in nonhuman primates and is altered during a cognitive task associated with cholinergic activation. These findings will serve to identify these targets intraoperatively and form the basis for further research to characterize the role of the nbM in cognition.
Minicraniotomy with a subgaleal pocket for the treatment of subdural fluid collections in infants
Authors: Palmer Angela W. , Albert Gregory W.
Published: February 2019

OBJECTIVE

Various surgical techniques have been described to treat subdural fluid collections in infants, including transfontanelle aspiration, burr holes, subdural drain, subduroperitoneal shunt, and minicraniotomy. The purpose of this study was to describe a modification of the minicraniotomy technique that avoids the implantation of external drainage catheters and potentially carries a higher success rate.

METHODS

In this retrospective study, the authors describe 11 cases involving pediatric patients who underwent parietal minicraniotomies for the evacuation of subdural fluid collections. In contrast to cases previously described in the literature, no patient received a drain; instead, a subgaleal pocket was created such that the fluid could flow from the subdural to the subgaleal space. Preoperative and postoperative data were reviewed, including neurological examination findings, radiological findings, complications, hospital length of stay, and findings on follow-up examinations and imaging. The primary outcome was failure of the treatment strategy, defined as an increase in subdural fluid collection requiring further intervention.

RESULTS

Eleven patients (8 boys and 3 girls, median age 4.5 months) underwent the described procedure. Eight of the patients had complete resolution of the subdural collection on follow-up imaging, and 2 had improvement. One patient had a new subdural collection due to a second injury. Only 1 patient underwent aspiration and subsequent surgical repair of a pseudomeningocele after the initial surgery. Notably, no patients required subduroperitoneal shunt placement.

CONCLUSIONS

The authors describe a new surgical option for subdural fluid collections in infants that allows for more aggressive evacuation of the subdural fluid and eliminates the need for a drain or shunt placement. Further work with more patients and direct comparison to other alternative therapies is necessary to fully evaluate the efficacy and safety of this new technique.
Neurosurgical treatment of pediatric pleomorphic xanthoastrocytomas: long-term follow-up of a single-institution, consecutive series of 12 patients
Authors: Lundar Tryggve , Due-Tønnessen Bernt Johan , Frič Radek , Krossnes Bård , Brandal Petter , Stensvold Einar , Due-Tønnessen Paulina
Published: February 2019

OBJECTIVE

The authors conducted a study to delineate the long-term results of the surgical treatment of pediatric pleomorphic xanthoastrocytomas (PXAs).

METHODS

All consecutive children and adolescents (0–20 years) who underwent primary tumor resection for a PXA during the years 1972–2015 were included in this retrospective study on surgical morbidity, mortality rate, academic achievement, and/or work participation. Gross motor function and activities of daily living were scored according to the Barthel Index.

RESULTS

Of the 12 patients, 8 patients were in the 1st decade of life and 4 in the 2nd. The male/female ratio was 6:6. No patient was lost to follow-up. One patient presented with severe progressive tumor disease and died within 3 months after repeated resection. Another child died 3 days following a second surgical procedure involving gross-total resection (GTR) 8 years after the initial operation. The other 10 patients were alive at the latest follow-up when they reached the median age of 34 years (range 11–60 years). The median follow-up duration was 22 years (range 2–41 years). Barthel Index score was 100 in all 10 survivors. A total 18 tumor resections were performed. Five patients underwent a second tumor resection after MRI/CT confirmed recurrent tumor disease, from 6 months up to 17 years after the initial operation. Only one of our patients received adjuvant therapy: a 19-year-old male who underwent resection (GTR) for a right-sided temporal tumor in 1976. This particular tumor was originally classified as astrocytoma WHO grade IV, and postoperative radiotherapy (54 Gy) was given. The histology was reclassified to that of a PXA. Seven of 8 children whose primary tumor resection was performed more than 20 years ago are alive as of this writing—i.e., 88% observed 20-year survival. These are long-term survivors with good clinical function and all are in full- or part-time work.

CONCLUSIONS

Pediatric patients with PXA can be treated with resection alone with rewarding results. Recurrences are not uncommon, but repeated surgery is well tolerated and should be considered in low-grade cases before adjuvant therapy is implemented. Follow-up including repeated MRI is important during the first postoperative years, since individual patients may have a more aggressive tumor course.