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Erdman M.J.,University of Florida | Doepker B.A.,Ohio State University | Gerlach A.T.,Ohio State University | Phillips G.S.,Ohio State University | And 4 more authors.
Critical Care Medicine | Year: 2014

OBJECTIVE:: Dexmedetomidine and propofol are commonly used sedatives in neurocritical care as they allow for frequent neurologic examinations. However, both agents are associated with significant hemodynamic side effects. The primary objective of this study is to compare the prevalence of severe hemodynamic effects in neurocritical care patients receiving dexmedetomidine and propofol. DESIGN:: Multicenter, retrospective, propensity-matched cohort study. SETTING:: Neurocritical care units at two academic medical centers with dedicated neurocritical care teams and board-certified neurointensivists. PATIENTS:: Neurocritical care patients admitted between July 2009 and September 2012 were evaluated and then matched 1:1 based on propensity scoring of baseline characteristics. INTERVENTIONS:: Continuous sedation with dexmedetomidine or propofol. MEASUREMENTS AND MAIN RESULTS:: A total of 342 patients (105 dexmedetomidine and 237 propofol) were included in the analysis, with 190 matched (95 in each group) by propensity score. The primary outcome of this study was a composite of severe hypotension (mean arterial pressure < 60 mm Hg) and bradycardia (heart rate < 50 beats/min) during sedative infusion. No difference in the primary composite outcome in both the unmatched (30% vs 30%, p = 0.94) or matched cohorts (28% vs 34%, p = 0.35) could be found. When analyzed separately, no differences could be found in the prevalence of severe hypotension or bradycardia in either the unmatched or matched cohorts. CONCLUSIONS:: Severe hypotension and bradycardia occur at similar prevalence in neurocritical care patients who receive dexmedetomidine or propofol. Providers should similarly consider the likelihood of hypotension or bradycardia before starting either sedative. © 2014 by the Society of Critical Care Medicine.


Klimo Jr. P.,Semmes Murphey Neurologic and Spine Institute | Klimo Jr. P.,University of Tennessee Health Science Center | Thompson C.J.,George Washington University | Ragel B.T.,Oregon Health And Science University | And 2 more authors.
Journal of Neurosurgery | Year: 2014

Object. Neurosurgeons are inundated with vast amounts of new clinical research on a daily basis, making it difficult and time-consuming to keep up with the latest literature. Meta-analysis is an extension of a systematic review that employs statistical techniques to pool the data from the literature in order to calculate a cumulative effect size. This is done to answer a clearly defined a priori question. Despite their increasing popularity in the neurosurgery literature, meta-analyses have not been scrutinized in terms of reporting and methodology. Methods. The authors performed a literature search using PubMed/MEDLINE to locate all meta-analyses that have been published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Accepted checklists for reporting (PRISMA) and methodology (AMSTAR) were applied to each meta-analysis, and the number of items within each checklist that were satisfactorily fulfilled was recorded. The authors sought to answer 4 specific questions: Are meta-analyses improving 1) with time; 2) when the study met their definition of a meta-analysis; 3) when clinicians collaborated with a potential expert in meta-analysis; and 4) when the meta-analysis was the only focus of the paper? Results. Seventy-two meta-analyses were published in the JNS Publishing Group journals and Neurosurgery between 1990 and 2012. The number of published meta-analyses has increased dramatically in the last several years. The most common topics were vascular, and most were based on observational studies. Only 11 papers were prepared using an established checklist. The average AMSTAR and PRISMA scores (proportion of items satisfactorily fulfilled divided by the total number of eligible items in the respective instrument) were 31% and 55%, respectively. Major deficiencies were identified, including the lack of a comprehensive search strategy, study selection and data extraction, assessment of heterogeneity, publication bias, and study quality. Almost one-third of the papers did not meet our basic definition of a meta-analysis. The quality of reporting and methodology was better 1) when the study met our definition of a meta-analysis; 2) when one or more of the authors had experience or expertise in conducting a meta-analysis; 3) when the meta-analysis was not conducted alongside an evaluation of the authors' own data; and 4) in more recent studies. Conclusions. Reporting and methodology of meta-analyses in the neurosurgery literature is excessively variable and overall poor. As these papers are being published with increasing frequency, neurosurgical journals need to adopt a clear definition of a meta-analysis and insist that they be created using checklists for both reporting and methodology. Standardization will ensure high-quality publications. © AANS, 2014.


Taylor D.R.,University of Tennessee Health Science Center | Weaver J.A.,Semmes Murphey Neurologic and Spine Institute
Journal of Neurosurgery: Spine | Year: 2015

Radiosurgery for primary and metastatic tumors of the central nervous system is increasing in utility and intensity. Known complications in the brain include radiation necrosis and the well-documented phenomenon of pseudoprogression. Known complications of radiosurgery to spinal column tumors include radiation myelopathy and delayed vertebral compression fractures; however, the concept of pseudoprogression of spinal column tumors has not been previously described. The authors review 2 cases of spinal metastasis treated with stereotactic radiosurgery (SRS) and attempt to define the concept of spine tumor pseudoprogression. Two patients who had undergone SRS to the spine for metastatic disease presented in early follow-up (3 and 7 weeks) with symptomatic complaints consisting of axial pain, radicular pain, or evidence of cord compression. In both patients, MRI revealed evidence of tumor enlargement. In one patient, the lesion had grown by 9 mm and 7.7 mm in the axial and sagittal planes, respectively. In the other patient, the tumor growth resulted in a 5-mm decrease in spinal canal diameter with epidural compression and right foraminal encroachment. Because of the absence of progressive neurological deficit, myelopathy, mechanical symptomatology of instability, or vertebral compression fracture, the first patient was treated expectantly with a corticosteroid taper and had improvement of symptoms at 1 month and near-total radiographic resolution of the tumor. In the second patient, worsening symptoms suggested a need for surgical intervention to address presumed radiosurgical failure and tumor progression. During surgery, only necrotic tumor cells were observed, without viable tumor. Follow-up imaging over 1 year showed ongoing local control. To their knowledge, the authors report the first description of pseudoprogression involving spinal column metastasis in the literature and aim to alert the treating physician to this clinical situation. Unlike brain tumor pseudoprogression, spine tumor pseudoprogression is a relatively early posttreatment phenomenon, measured in days to 2 months. The authors believe that the acute inflammatory response associated with tumor necrosis and disruption of the tumor capillary integrity caused by radiotherapy is an important component in the development of pseudoprogression. Future studies will be fundamental in assigning clinical significance, defining the incidence and predictors, and affecting future management of this phenomenon. ©AANS, 2015.


Aquilina K.,Frenchay Hospital | Boop F.A.,Semmes Murphey Neurologic and Spine Institute
Journal of Neurosurgery: Pediatrics | Year: 2011

Primary neoplasms of the pituitary gland are uncommon in children. Physiological enlargement of the gland, however, is universal and can sometimes be confused with a tumor. Due to widespread availability of MR imaging, the number of children referred to pediatric neurosurgeons with an enlarged pituitary associated with nonspecific symptoms, most commonly headache, is increasing. In this review, the authors illustrate two common causes of pituitary enlargement in children, namely physiological hypertrophy of puberty, more commonly seen in females, and secondary hyperplasia caused by hypothyroidism. The importance of early and accurate diagnosis, without recourse to extensive endocrine investigations or inappropriate surgery, is underscored. ©1944-2011 by the American Association of Neurosurgeons.


Young J.C.,Memphis Veterans Affairs Medical Center | Sawyer R.J.,Memphis Veterans Affairs Medical Center | Roper B.L.,Memphis Veterans Affairs Medical Center | Baughman B.C.,Semmes Murphey Neurologic and Spine Institute
Clinical Neuropsychologist | Year: 2012

The Digit Span subtest was significantly revised for the WAIS-IV as an ordinal sequencing trial was added to increase working memory demands. The present investigation sought to validate an expanded version of Reliable Digit Span (RDS-R) as well as age-corrected scaled score (ACSS) from the recently revised Digit Span. Archival data were collected from 259 veterans completing the WAIS-IV Digit Span subtest and Word Memory Test (WMT). Veterans failing the WMT performed significantly worse (p<.001) on the ACSS, RDS-R, and traditional RDS. Operational characteristics of the ACSS, RDS-R, and RDS were essentially equivalent; however, sensitivity was quite modest when selecting cutoffs with strong specificity. While current results suggest that Digit Span effort indices can contribute to the detection of suboptimal effort, additional symptom validity indicators should be employed to compensate for limited sensitivity. © 2012 Copyright Taylor and Francis Group, LLC.


DeCuypere M.,University of Tennessee Health Science Center | Klimo P.,University of Tennessee Health Science Center | Klimo P.,Semmes Murphey Neurologic and Spine Institute | Klimo P.,LeBonheur Childrens Hospital
Surgical Clinics of North America | Year: 2012

Traumatic brain injury (TBI) involves significant damage of the brain parenchyma, and is the leading cause of morbidity and mortality after trauma. It is thus essential for all physicians involved in acute care medicine and surgery to have a thorough understanding of TBI. Management of the patient with TBI is a rapidly advancing field, characterized by an improved understanding of intracranial pathophysiology and decreasing overall mortality largely because of improved neurocritical and surgical care. This article summarizes the classification system, management approaches, and recent controversies in the care of mild, moderate, and severe TBI. © 2012 Elsevier Inc.


Klimo P.,Semmes Murphey Neurologic and Spine Institute | Coon V.,University of Utah | Brockmeyer D.,University of Utah
Neurosurgical Focus | Year: 2011

Os odontoideum was first described in the late 1880s and still remains a mystery in many respects. The genesis of os odontoideum is thought to be prior bone injury to the odontoid, but a developmental cause probably also exists. The spectrum of presentation is striking and ranges from patients who are asymptomatic or have only neck pain to those with acute quadriplegia, chronic myelopathy, or even sudden death. By definition, the presence of an os odontoideum renders the C1-2 region unstable, even under physiological loads in some patients. The consequences of this instability are exemplified by numerous cases in the literature in which a patient with os odontoideum has suffered a spinal cord injury after minor trauma. Although there is little debate that patients with os odontoideum and clinical or radiographic evidence of neurological injury or spinal cord compression should undergo surgery, the dispute continues regarding the care of asymptomatic patients whose os odontoideum is discovered incidentally. The authors' clinical experience leads them to believe that certain subgroups of asymptomatic patients should be strongly considered for surgery. These subgroups include those who are young, have anatomy favorable for surgical intervention, and show evidence of instability on flexion-extension cervical spine x-rays. This recommendation is bolstered by the fact that surgical fusion of the C1-2 region has evolved greatly and can now be done with considerable safety and success. When atlantoaxial instrumentation is used, fusion rates for os odontoideum should approach 100%.


Willard V.W.,St Jude Childrens Research Hospital | Conklin H.M.,St Jude Childrens Research Hospital | Boop F.A.,St Jude Childrens Research Hospital | Boop F.A.,Semmes Murphey Neurologic and Spine Institute | And 2 more authors.
International Journal of Radiation Oncology Biology Physics | Year: 2014

Purpose The standard of care for pediatric patients with ependymoma involves postoperative radiation therapy. Prior research suggests that conformal radiation therapy (CRT) is associated with relative sparing of cognitive and academic functioning, but little is known about the effect of CRT on emotional and behavioral functioning. Methods and Materials A total of 113 patients with pediatric ependymoma underwent CRT using photons as part of their enrollment on an institutional trial. Patients completed annual evaluations of neurocognitive functioning during the first 5 years after CRT. Emotional and behavioral functioning was assessed via the Child Behavior Checklist. Results Before CRT, emotional and behavioral functioning were commensurate with those of the normative population and within normal limits. After 5 years, means remained within normal limits but were significantly below the normative mean. Linear mixed models revealed a significant increase in attention problems over time. These problems were associated with age at diagnosis/CRT, tumor location, and extent of resection. A higher-than-expected incidence of school problems was present at all assessment points after baseline. Conclusions The use of photon CRT for ependymoma is associated with relatively stable emotional and behavioral functioning during the first 5 years after treatment. The exception is an increase in attention problems. Results suggest that intervening earlier in the survivorship period - during the first year posttreatment - may be beneficial. © 2014 Elsevier Inc. All rights reserved.


Merchant T.E.,St Jude Childrens Research Hospital | Kun L.E.,St Jude Childrens Research Hospital | Hua C.-H.,St Jude Childrens Research Hospital | Wu S.,St Jude Childrens Research Hospital | And 3 more authors.
International Journal of Radiation Oncology Biology Physics | Year: 2013

Purpose: To estimate the rate of disease control after conformal radiation therapy using reduced clinical target volume (CTV) margins and to determine factors that predict for tumor progression. Methods and Materials: Eighty-eight children (median age, 8.5 years; range, 3.2-17.6 years) received conformal or intensity modulated radiation therapy between 1998 and 2009. The study group included those prospectively treated from 1998 to 2003, using a 10-mm CTV, defined as the margin surrounding the solid and cystic tumor targeted to receive the prescription dose of 54 Gy. The CTV margin was subsequently reduced after 2003, yielding 2 groups of patients: those treated with a CTV margin greater than 5 mm (n=26) and those treated with a CTV margin less than or equal to 5 mm (n=62). Disease progression was estimated on the basis of additional variables including sex, race, extent of resection, tumor interventions, target volume margins, and frequency of weekly surveillance magnetic resonance (MR) imaging during radiation therapy. Median follow-up was 5 years. Results: There was no difference between progression-free survival rates based on CTV margins (>5 mm vs ≤5 mm) at 5 years (88.1% ± 6.3% vs 96.2% ± 4.4% [P=.6386]). There were no differences based on planning target volume (PTV) margins (or combined CTV plus PTV margins). The PTV was systematically reduced from 5 to 3 mm during the time period of the study. Factors predictive of superior progression-free survival included Caucasian race (P=.0175), no requirement for cerebrospinal fluid shunting (P=.0066), and number of surveillance imaging studies during treatment (P=.0216). Patients whose treatment protocol included a higher number of weekly surveillance MR imaging evaluations had a lower rate of tumor progression. Conclusions: These results suggest that targeted volume reductions for radiation therapy using smaller margins are feasible and safe but require careful monitoring. We are currently investigating the differences in outcome based on host factors to explain the results. © 2013 Elsevier Inc. All rights reserved.


Young J.C.,Memphis Veterans Affairs Medical Center | Baughman B.C.,Semmes Murphey Neurologic and Spine Institute | Roper B.L.,Memphis Veterans Affairs Medical Center
Clinical Neuropsychologist | Year: 2012

The RBANS Effort Index (RBANS-EI; Silverberg, Wertheimer, & Fichtenberg, 2007) is an embedded measure of effort within a frequently employed neuropsychological screening battery. While it has been criticized for inadequate specificity in older non-litigating samples (Hook, Marquine, & Hoelzle, 2009; Warren etal., 2010), the RBANS-EI has yet to be investigated in a non-geriatric veteran sample. Archival data were collected from 85 veterans who completed the RBANS and WMT within either a routine neuropsychological evaluation (n=66) or compensation evaluation (n=19). At a cutoff of >3 RBANS-EI exhibited strong specificity (.94) yet limited sensitivity (.31) in the prediction of WMT performance. Examination of RBANS-EI component subtests found that List Recognition <17 had strong specificity (.90) and moderate sensitivity (.52) in discriminating WMT performance groups. In contrast, Digit Span performance was comparable between those passing and failing the WMT. Present findings indicate that both the RBANS-EI and List Recognition subtest may be useful in detecting suboptimal effort yet raise questions regarding the Digit Span component of the RBANS-EI. © 2012 Taylor & Francis Group, LLC.

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