Huelser, Matthias J. M.

Oertel, Joachim M. K.

Acta Neurochirurgica

English

Objectives!#!This study aimed to assess the survival of direct composite restorations placed under general anesthesia in adult patients with intellectual and/or physical disabilities.!##!Materials and methods!#!Survival of composite restorations placed under general anesthesia in adult patients with intellectual and/or physical disabilities was retrospectively analyzed. Failure was defined as the need for replacement of at least one surface of the original restoration or extraction of the tooth. Individual-, tooth-, and restoration-related factors were obtained from dental records. Five-year mean annual failure rate (mAFR) and median survival time were calculated (Kaplan-Meier statistics). The effect of potential risk factors on failure was tested using univariate log-rank tests and multivariate Cox-regression analysis (α = 5%).!##!Results!#!A total of 728 restorations in 101 patients were included in the analysis. The survival after 5 years amounted to 67.7% (5-year mAFR: 7.5%) and median survival time to 7.9 years. Results of the multivariate Cox-regression analysis revealed physical disability (HR: 50.932, p = 0.001) and combined intellectual/physical disability (HR: 3.145, p = 0.016) compared with intellectual disability only, presence of a removable partial denture (HR: 3.013, p &amp;lt; 0.001), and restorations in incisors (HR: 2.281, p = 0.013) or molars (HR: 1.693, p = 0.017) compared with premolars to increase the risk for failure.!##!Conclusion!#!Composite restorations placed under general anesthesia in adult patients with intellectual and/or physical disabilities showed a reasonable longevity as 67.7% survived at least 5 years.!##!Clinical relevance!#!Survival of composite restorations depends on risk factors that need to be considered when planning restorative treatment in patients with intellectual and/or physical disabilities. NCT04407520

, Joachim

Hochschulbibliothekszentrum des Landes Nordrhein-Westfalen (hbz)

Predicting the outcome of normal pressure hydrocephalus therapy—where do we stand?

Acronym

EDITORIAL (BY INVITATION)Predicting the outcome of normal pressurehydrocephalus therapy—where do we stand?Joachim M. K. Oertel1 & Matthias J. M. Huelser1Received: 23 December 2020 /Accepted: 28 December 2020# The Author(s) 2021Normal-pressure hydrocephalus (NPH) is a treatable disease.It is the only form of dementia for which we do have effectivetreatment modalities. Permanent cerebrospinal fluid diversionvia shunt insertion is the gold standard. The objective re-sponse to the shunt treatment is about 85% [6], at least for acertain time. The majority of patients (85 %) respond to thistreatment, but what about the other 15%? How can we predictwhich patient will respond to treatment and who will not?Well, the first step consists of being certain about the correctdiagnosis, which can be tricky since the pathophysiology ofNPHremains not entirely understood. Then, the most challenging as-pect is to decide which patient will respond and who will not.There are plenty of studies investigating the predictors ofshunt response.First of all, what about acquired risk factors? The existenceof more than one cardiovascular risk factor seems to be areliable clinical predictor for a negative outcome in normalpressure hydrocephalus [9]. Solely, age does not account asa risk factor [9, 11].Commonly, the most important positive predictors fortreatment response are considered to be the spinal tab test orcontinuous lumbar drainage. Even though, the only blindedprospective study on this subject demonstrated a positive pre-dictive value of 88%, but also a negative predictive value of18% [23]. This results only in an overall accuracy of 53% [6,23]. Furthermore, continuous lumbar drainage over a few daysshows very high positive predictive values, but it has also lownegative predictive values [14], so in conclusion, a response toa lumbar drainage test correlates well with a positive responseto shunt treatment [8], but a non-response should not excludethe patient from treatment [23], so this nonresponsive patientcohort should be subject to further investigations.What about radiological findings predicting a treatment re-sponse? One study investigated 168 patients with normal pres-sure hydrocephalus for an association of certain radiologicalsigns, such as disproportionately enlarged subarachnoid spacehydrocephalus (DESH) sign, Evans-index, and callosal angle(CA), with the patient outcome after shunt treatment. In thisstudy, no correlation betweenMRI findings and outcome couldbe demonstrated [1]. Additionally, the absence or presence ofperiventricular hyperintensities did not seem to correlate [10].Although some evidence exists that the DESH sign corre-lates with a positive response to shunt therapy [7, 22], aug-mented postischaemic lacunes may imply a rather worse pa-tient outcome [7].In addition, in a study from 2014, the authors could showthat a preoperative steeper CA correlated with a better re-sponse to surgery [21].Similarly, the findings ofMantovani et al. that will be present-ed in the following demonstrated in their recent study with astatistically significant correlation of the so-called anteriorcallosal angle (ACA) with an improvement of gait and balance.Furthermore, three studies with a fair amount of scientificevidence were able to relate a higher aqueduct velocity withpositive responsiveness, especially in cases where a cerebro-spinal infusion test had been pathological [2, 5, 16].Furthermore, the reactivity of cerebral blood flow to acet-azolamide (measured in prospective study via SPECT) seemsto correlate significantly with a response to shunt treatment [3].Measurement of ICP dynamics is an invasive but usefulmodality to clarify the question of responsiveness to treat-ment. Increased outflow resistance during a CSF infusion testseems to be a predictor [13, 19, 23]. Furthermore, pulsatileICP like pulse pressure amplitudes and vasogenic slow wavescan be used for forecasting treatment success [18, 20].Lastly, there remains the question of whether or not pa-tients with Alzheimer’s disease as comorbidity (up to 19%of cases [17]) to NPH are eligible for shunt treatment? This* Joachim M. K. OertelJoachim.oertel@uks.eu1 Department of Neurosurgery, Saarland University Medical Centerand Saarland University Faculty of Medicine, Homburg, Saar,Germanyhttps://doi.org/10.1007/s00701-020-04700-3/ Published online: 20 January 2021Acta Neurochirurgica (2021) 163:767–769cannot be answered at this point sufficiently [12, 15]. There issome evidence that phospho-tau as a CSF biomarker seems tohave a predictive value for higher postoperative morbidity buton the contrary, there is also data suggesting that patients withcomorbid neurodegenerative diseases responded well to shunttreatment [4], but how does this scientific data translate intoclinical practice?In our opinion, the first step is performing a spinal tab teston patients with typical clinical signs and imaging findings forNPH. A special focus should be on the CA, in particular theACA, when evaluating such as patient imaging. In cases ofclinical improvement after spinal tab testing, shunt replace-ment therapy can be recommended, regardless of supposedlynegative predictors. In cases of nonresponsiveness or contra-indications for spinal tab testing, further diagnostic investiga-tions such as SPECT imaging, measurement of aqueduct ve-locity or CSF infusion test, depending on the individual centerexpertise, may be helpful. In our center, ICP dynamics viatelemetric measurement has proven to be a very valuable toolin such cases. In conclusion, despite there being negative pre-dictors for shunt therapy, it is important that one weighs thepositive against the negative predictors in individual decision-making for shunt surgery, and that the value of negative pre-dictors should not be overestimated and therefore result in apatient not receiving adequate therapy.Funding Open Access funding enabled and organized by Projekt DEAL.Open Access This article is licensed under a Creative CommonsAttribution 4.0 International License, which permits use, sharing, adap-tation, distribution and reproduction in any medium or format, as long asyou give appropriate credit to the original author(s) and the source, pro-vide a link to the Creative Commons licence, and indicate if changes weremade. 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Predicting the outcome of normal pressure hydrocephalus therapy-where do we stand?

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https://publikationen.sulb.uni-saarland.de/bitstream/20.500.11880/31193/1/Oertel-Huelser2021_Article_PredictingTheOutcomeOfNormalPr.pdf

Predicting the outcome of normal pressure hydrocephalus therapy-where do we stand?

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Hochschulbibliothekszentrum des Landes Nordrhein-Westfalen (hbz)

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