20 research outputs found
Continuous monitoring of partial pressure of brain tissue oxygen in patients with severe head injury
Impact of medical treatment on the outcome of patients after aneurysmal subarachnoid hemorrhage
BACKGROUND AND PURPOSE: The rationale behind early aneurysm surgery in
patients with subarachnoid hemorrhage (SAH) is the prevention of
rebleeding as early as possible after SAH. In addition, by clipping the
aneurysm as early as possible, one can apply treatment for cerebral
ischemia more vigorously (induced hypertension) without the risk of
rebleeding. Hypervolemic hemodilution is now a well-accepted treatment for
delayed cerebral ischemia. We compared the prospectively collected
clinical data and outcome of patients admitted to the intensive care unit
in the period 1977 to 1982 with those of patients admitted in the period
1989 to 1992 to measure the effect of the change in medical management
procedures on patients admitted in our hospital with SAH. METHODS: We
studied 348 patients admitted within 72 hours after aneurysmal SAH.
Patients with negative angiography results and those in whom death
appeared imminent on admission were excluded. The first group (group A)
consisted of 176 consecutive patients admitted from 1977 through 1982.
Maximum daily fluid intake was 1.5 to 2 L. Hyponatremia was treated with
fluid restriction (<1 L/24 h). Antihypertensive treatment with diuretic
agents was given if diastolic blood pressure was >110 mm Hg. Patients in
the second group (172 consecutive patients; group B) were admitted from
1989 through 1992. Daily fluid intake was at least 3 L, unless cardiac
failure occurred. Diuretic agents and antihypertensive medications were
avoided. Cerebral ischemia was treated with vigorous plasma volume
expansion under intermittent monitoring of pulmonary wedge pressure,
cardiac output, and arterial blood pressure, aiming for a hematocrit of
0.29 to 0.33. Aneurysm surgery was planned for day 12. RESULTS: Patients
admitted in group B had less favorable characteristics for the development
of cerebral ischemia and for good outcome when compared with patients in
group A. Despite this, we found a significant decrease in the frequency of
delayed cerebral ischemia in patients of group B treated with tranexamic
acid (P=0.00005 by log rank test) and significantly improved outcomes
among patients with delayed cerebral ischemia (P=0.006 by chi2 test) and
among patients with deterioration from hydrocephalus (P=0.001 by chi2
test). This resulted in a significant improvement of the overall outcome
of patients in group B when compared with those in group A (P=0.006 by
chi2 test). The major cause of death in group B was rebleeding (P=0.011 by
chi2 test). CONCLUSIONS: We conclude that the outcome in our patients with
aneurysmal SAH was improved but that rebleeding remains a major cause o
Treatment of malignant gliomas with a replicating adenoviral vector expressing herpes simplex virus-thymidine kinase
We evaluated the interaction between oncolytic, replication-competent
adenoviral vectors and the herpes simplex virus-1 thymidine kinase
(HSV1-tk) gene/ganciclovir (GCV) suicide system for the treatment of
malignant gliomas. We constructed a panel of replication-competent
adenoviral vectors in which the luciferase (IG.Ad5E1(+). E3Luc) or HSV1-tk
gene (IG.Ad5E1(+).E3TK) replace the M(r) 19,000 glycoprotein (gp19K)
coding sequence in the E3 region. IG.Ad5E1. IG.Ad5.ClipLuc and IG.AdApt.TK
are E1-deleted viruses that contain the luciferase or the HSV1-tk gene in
the former E1 region driven by the human cytomegalovirus promoter.
IG.Ad5.Sarcoma 1800HSA.E3Luc contains an irrelevant gene in the E1 region,
whereas the gp19K coding sequence in the E3 region is replaced by the
luciferase gene as in the replicating virus IG.Ad5E1(+).E3Luc. For in
vitro experiments, we used a panel of human glioma cell lines (U87 MG,
T98G, A172, LW5, and U251), a rat gliosarcoma cell line (9 L), and human
lung (A549) and prostate carcinoma (P3) cell lines. In vitro, GCV
sensitivity (10 microg/ml) was studied in U87 MG cells after infection at
a multiplicity of infection of 1 and 10. A s.c. U87 MG glioma xenograft
model was established in NIH-bg-nu-xid mice. Tumors of 100-150 mm(3) were
treated with a single injection of adenovirus 10(9) IU suspended in 100
microl of PBS, and GCV 100 mg/kg was administered i.p. twice daily for 7
days. The cytopathic effect of all three replication-competent adenoviral
vectors was similar to the cytopathic effect of wild-type adenovirus 5 on
all human cell lines tested, indicating that deletion of the E3 gp19K
sequences did not affect the oncolytic effect of the vectors. In vitro,
luciferase expression was the same for both E1-deleted vectors
(IG.Ad5.ClipLuc and IG.Ad5.Sarcoma 1800HSA.E3Luc), demonstrating the
strength of the internal E3 promoter even in the absence of E1A. However,
in vitro expression levels obtained with replication-competent
IG.Ad5E1(+). E3Luc were 3 log higher (allowing infection with a
Cerebrospinal fluid pulse pressure and craniospinal dynamics : a theoretical, clinical and experimental study
Since the introduction of continuous recording of intracranial pressure
(ICP) in neurosurgical practice (Guillaume and Janny, 1951; Lundberg,
1960) this method has greatly contributed to clinical research in the
field of intracranial hypertension. Numerous publications have enriched
the literature on ICP and five International Symposia (1972, 1974, 1976,
1979 and 1982) on the subject have been held. The knowledge gained from
these investigations has considerably benefited the management of patients
suffering from raised ICP. However, in spite of the enthousiasm among
those who practise ICP monitoring, the method h
Do neurosurgeons subscribe to the guideline lumbosacral radicular syndrome?
Background: This study presents a survey of the opinion of neurosurgeons on the multidisciplinary clinical guideline 'lumbosacral radicular syndrome'. The aim was to describe to what extent neurosurgeons in the Netherlands endorse the content of this guideline. The guideline was issued in 1996 by the Netherlands Institute of Quality Health Care and this is the first attempt to evaluate the implementation of this guideline. Methods: All active neurosurgeons (n=92) in the Netherlands were invited to complete a questionnaire investigating to what extent they agree with the 26 recommendations in the guideline 'lumbosacral radicular syndrome'. The results are represented in frequencies (%) in order to express the magnitude of their consent or dissent with the recommendations. Results: Overall, 75% of the neurosurgeons responded and, of these, 94% agreed (at least partially) with the content of the guideline. Of the 26 recommendations in the guideline, seven were not fully endorsed by the neurosurgeons. Three of these seven recommendations may need revision based on newly published data. Conclusion: This survey shows that almost all neurosurgeons subscribed (at least partially) to the multidisciplinary LRS guideline. Therefore, one important aspect of the implementation process has been fulfilled, i.e. acceptance of the content of the guideline
Organ donation as transition work:Policy discourse and clinical practice in The Netherlands
An increasing number of patients become eligible for organ transplants. In the Netherlands, at the level of policy discourse, growing waiting lists are often referred to as a persistent “shortage” of organs, producing a “public health crisis.” In this way, organ donation is presented as an ethical, social, and medical necessity. Likewise, policy discourse offers a range of seemingly unambiguous solutions: improving logistical infrastructure at the level of hospitals, developing organizational and legal protocols, as well as public information campaigns. Instead of taking these problem and solution definitions as given, we critically examine the relationship between policy discourse and clinical practice. Based on a historical review, first, we trace the key moments of transformation where organ donation became naturalized in Dutch policy discourse, particularly in its altruistic connotation. Second, based on in-depth interviews with medical professionals, we show how those involved in organ donation continue to struggle with the controversial nature of their clinical practice. More specifically, we highlight their use of different forms of knowledge that underlie clinicians’ “transition work”: from losing a patient to “gaining” a donor. Keywords: death dying and bereavement, health policy, profession and professionalization, research methodology, technology in health car
Conus-cauda syndrome as a presenting symptom of endodermal sinus tumor of the ovary
We report on a case of a 46-year-old woman with a conus-cauda syndrome due to an endodermal sinus tumor of the right ovary with multiple metastases in the spine and pelvic bone. Before removing the tumor surgically, combination chemotherapy was given to treat the metastases, which threatened to compromise the spinal cord
Neurosurgeons' management of lumbosacral radicular syndrome evaluated against a clinical guideline
To establish to what extent neurosurgeons subscribe to the lumbosacral radicular syndrome (LRS) guideline, and to evaluate their current management of patients with LRS against the guideline. All active neurosurgeons in the Netherlands (n=92) were mailed a questionnaire about the guideline and data from 66 responders were analysed. Patients were recruited via seven of the participating neurosurgeons and were interviewed once by telephone. The medical records of the participating patients (n=163) were also examined. Of the 26 propositions in the LRS guideline, seven were not fully endorsed by the neurosurgeons. Three of these seven propositions may need updating based on "new evidence". The time between the onset of the LRS episode and the actual moment of surgery was considerably longer than that recommended in the guideline. Based on their current management of LRS patients, the neurosurgeons largely adhere with the LRS guideline